+-------------------------+----------------------------+---------------+
| **PHA Plans**           | **U.S. Department of       | OMB No.       |
|                         | Housing and Urban          | 2577-0226     |
| **Streamlined Annual**  | Development**              |               |
|                         |                            | (exp.         |
| **Version**             | Office of Public and       | 08/31/2009)   |
|                         | Indian Housing             |               |
+-------------------------+----------------------------+---------------+

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

This information collection is authorized by Section 511 of the Quality
Housing and Work Responsibility Act, which added a new section 5A to the
U.S. Housing Act of 1937 that introduced 5-year and annual PHA Plans.
The full PHA plan provides a ready source for interested parties to
locate basic PHA policies, rules, and requirements concerning the PHA's
operations, programs, and services, and informs HUD, families served by
the PHA, and members of the public of the PHA's mission and strategies
for serving the needs of low-income and very low-income families. This
form allows eligible PHAs to make a streamlined annual Plan submission
to HUD consistent with HUD's efforts to provide regulatory relief for
certain types of PHAs. Public reporting burden for this information
collection is estimated to average 11.7 hours per 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. HUD may not collect this information and
respondents are not required to complete this form, unless it displays a
currently valid OMB Control Number.

**Privacy Act Notice.** The United States Department of Housing and
Urban Development, Federal Housing Administration, is authorized to
solicit the information requested in this form by virtue of Title 12,
U.S. Code, Section 1701 et seq., and regulations promulgated thereunder
at Title 12, Code of Federal Regulations. Information in PHA plans is
publicly available.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Streamlined Annual PHA Plan**

**for Fiscal Year: 20\_\_\_**

**PHA Name:**

**NOTE: This PHA Plan template (HUD-50075-SA) is to be completed in
accordance with instructions contained in previous Notices PIH 99-33
(HA), 99-51 (HA), 2000-22 (HA), 2000-36 (HA), 2000-43 (HA), 2001-4 (HA),
2001-26 (HA), 2003-7 (HA), and any related notices HUD may subsequently
issue.**

**Streamlined Annual PHA Plan**

**Agency Identification**

**PHA Name:** **PHA Number:**

**PHA Fiscal Year Beginning: (mm/yyyy)**

**PHA Programs Administered**:

**Public Housing and Section 8** **Section 8 Only** **Public Housing
Only**

Number of public housing units: Number of S8 units: Number of public
housing units:

Number of S8 units:

**PHA Consortia: (check box if submitting a joint PHA Plan and complete
table)**

+-----------------------+------+--------------+-------------+---------+
| **Participating       | **P  | **Program(s) | **Programs  | **\# of |
| PHAs**                | HA** | Included in  | Not in the  | Units   |
|                       |      | the          | C           | Each    |
|                       | **Co | Consortium** | onsortium** | Pr      |
|                       | de** |              |             | ogram** |
+-----------------------+------+--------------+-------------+---------+
|                       |      |              |             |         |
+-----------------------+------+--------------+-------------+---------+
| **Participating PHA   |      |              |             |         |
| 1:**                  |      |              |             |         |
+-----------------------+------+--------------+-------------+---------+
|                       |      |              |             |         |
+-----------------------+------+--------------+-------------+---------+
| **Participating PHA   |      |              |             |         |
| 2:**                  |      |              |             |         |
+-----------------------+------+--------------+-------------+---------+
|                       |      |              |             |         |
+-----------------------+------+--------------+-------------+---------+
| **Participating PHA   |      |              |             |         |
| 3:**                  |      |              |             |         |
+-----------------------+------+--------------+-------------+---------+
|                       |      |              |             |         |
+-----------------------+------+--------------+-------------+---------+

**PHA Plan Contact Information:**

Name: Phone:

TDD: Email (if available):

**Public Access to Information**

**Information regarding any activities outlined in this plan can be
obtained by contacting: (select all that apply)**

PHA's main administrative office PHA's development management offices

**Display Locations For PHA Plans and Supporting Documents**

The PHA Plan revised policies or program changes (including attachments)
are available for public review and inspection. Yes No.

If yes, select all that apply:

Main administrative office of the PHA

PHA development management offices

Main administrative office of the local, county or State government

Public library PHA website Other (list below)

PHA Plan Supporting Documents are available for inspection at: (select
all that apply)

Main business office of the PHA PHA development management offices

Other (list below)

######### Streamlined Annual PHA Plan

**Fiscal Year 20**

\[24 CFR Part 903.12(c)\]

**[Table of Contents]{.underline}**

\[24 CFR 903.7(r)\]

### Provide a table of contents for the Plan*,* including applicable additional requirements, and a list of supporting documents available for public inspection*.* 

### 

### A. PHA PLAN COMPONENTS

 1. Site-Based Waiting List Policies

**903.7(b)(2) Policies on Eligibility, Selection, and Admissions**

2. Capital Improvement Needs

**903.7(g) Statement of Capital Improvements Needed**

3. Section 8(y) Homeownership

**903.7(k)(1)(i) Statement of Homeownership Programs**

4. Project-Based Voucher Programs

5. PHA Statement of Consistency with Consolidated Plan. Complete only if
PHA has changed any policies, programs, or plan components from its last
Annual Plan.

6. Supporting Documents Available for Review

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

8. Capital Fund Program 5-Year Action Plan

### 

### B. SEPARATE HARD COPY SUBMISSIONS TO LOCAL HUD FIELD OFFICE 

**Form HUD-50076**, [*PHA Certifications of Compliance with the PHA
Plans and Related Regulations*: *Board Resolution to Accompany the
Streamlined Annual Plan*]{.underline} identifying policies or programs
the PHA has revised since submission of its last Annual Plan, and
including Civil Rights certifications and assurances the changed
policies were presented to the Resident Advisory Board for review and
comment, approved by the PHA governing board, and made available for
review and inspection at the PHA's principal office;

For PHAs Applying for Formula Capital Fund Program (CFP) Grants:

**Form HUD-50070**, *[Certification for a Drug-Free
Workplace;]{.underline}*

**Form HUD-50071**, *[Certification of Payments to Influence Federal
Transactions]{.underline}*; and

**Form SF-LLL &SF-LLLa**, *[Disclosure of Lobbying
Activities]{.underline}*.

**[1. Site-Based Waiting Lists (Eligibility, Selection, Admissions
Policies)]{.underline}**

\[24 CFR Part 903.12(c), 903.7(b)(2)\]

Exemptions: Section 8 only PHAs are not required to complete this
component.

**A. Site-Based Waiting Lists-Previous Year**

1.  Has the PHA operated one or more site-based waiting lists in the
    previous year? If yes, complete the following table; if not skip to
    B.

+---------------+---------+--------------+---------------+------------+
| **Site-Based  |         |              |               |            |
| Waiting       |         |              |               |            |
| Lists**       |         |              |               |            |
+---------------+---------+--------------+---------------+------------+
| **Development | **Date  | **Initial    | **Current mix | **Percent  |
| I             | Init    | mix of       | of Racial,    | change     |
| nformation**: | iated** | Racial,      | Ethnic or     | between    |
|               |         | Ethnic or    | Disability    | initial    |
| (Name,        |         | Disability   | Demographics  | and        |
| number,       |         | De           | since         | current    |
|               |         | mographics** | Initiation of | mix of     |
| location)     |         |              | SBWL**        | Racial,    |
|               |         |              |               | Ethnic, or |
|               |         |              |               | Disability |
|               |         |              |               | demo       |
|               |         |              |               | graphics** |
+---------------+---------+--------------+---------------+------------+
|               |         |              |               |            |
+---------------+---------+--------------+---------------+------------+
|               |         |              |               |            |
+---------------+---------+--------------+---------------+------------+
|               |         |              |               |            |
+---------------+---------+--------------+---------------+------------+
|               |         |              |               |            |
+---------------+---------+--------------+---------------+------------+

2.  What is the number of site based waiting list developments to which
    families may apply at one time?

3.  How many unit offers may an applicant turn down before being removed
    from the site-based waiting list?

4.   Yes No: Is the PHA the subject of any pending fair housing
    complaint by HUD or any court order or settlement agreement? If yes,
    describe the order, agreement or complaint and describe how use of a
    site-based waiting list will not violate or be inconsistent with the
    order, agreement or complaint below:

```{=html}
<!-- -->
```
B.  **Site-Based Waiting Lists -- Coming Year**

If the PHA plans to operate one or more site-based waiting lists in the
coming year, answer each of the following questions; if not, skip to
next component.

> 1\. How many site-based waiting lists will the PHA operate in the
> coming year?
>
> 2\. Yes No: Are any or all of the PHA's site-based waiting lists new
> for the upcoming year (that is, they are not part of a
> previously-HUD-approved site based waiting list plan)?
>
> If yes, how many lists?
>
> 3\. Yes No: May families be on more than one list simultaneously
>
> If yes, how many lists?
>
> 4\. Where can interested persons obtain more information about and
> sign up to be on the site-based waiting lists (select all that apply)?
>
> PHA main administrative office
>
> All PHA development management offices
>
> Management offices at developments with site-based waiting lists
>
> At the development to which they would like to apply
>
> Other (list below)

**[2. Capital Improvement Needs]{.underline}**

\[24 CFR Part 903.12 (c), 903.7 (g)\]

Exemptions: Section 8 only PHAs are not required to complete this
component.

### A. Capital Fund Program

1\. Yes No Does the PHA plan to participate in the Capital Fund Program
in the upcoming year? If yes, complete items 7 and 8 of this template
(Capital Fund Program tables). If no, skip to B.

2\. Yes No: Does the PHA propose to use any portion of its CFP funds to
repay debt incurred to finance capital improvements? If so, the PHA must
identify in its annual and 5-year capital plans the development(s) where
such improvements will be made and show both how the proceeds of the
financing will be used and the amount of the annual payments required to
service the debt. (Note that separate HUD approval is required for such
financing activities.).

**B. HOPE VI and Public Housing Development and Replacement Activities
(Non-Capital Fund)**

Applicability: All PHAs administering public housing. Identify any
approved HOPE VI and/or public housing development or replacement
activities not described in the Capital Fund Program Annual Statement.

1\. Yes No: Has the PHA received a HOPE VI revitalization grant? (if no,
skip to #3; if yes, provide responses to the items on the chart located
on the next page, copying and completing as many times as necessary).

1.  Status of HOPE VI revitalization grant(s):

+-----------------------------------------------------------------------+
| **HOPE VI Revitalization Grant Status**                               |
+-----------------------------------------------------------------------+
| a\. Development Name:                                                 |
|                                                                       |
| b\. Development Number:                                               |
+-----------------------------------------------------------------------+
| c\. Status of Grant:                                                  |
|                                                                       |
| > Revitalization Plan under development                               |
| >                                                                     |
| > Revitalization Plan submitted, pending approval                     |
| >                                                                     |
| > Revitalization Plan approved                                        |
|                                                                       |
| Activities pursuant to an approved Revitalization Plan underway       |
+-----------------------------------------------------------------------+

3\. Yes No: Does the PHA expect to apply for a HOPE VI Revitalization
grant in the

> Plan year?
>
> If yes, list development name(s) below:

4\. Yes No: Will the PHA be engaging in any mixed-finance development
activities for public housing in the Plan year? If yes, list
developments or activities below:

5\. Yes No: Will the PHA be conducting any other public housing
development or replacement activities not discussed in the Capital Fund
Program Annual Statement? If yes, list developments or activities below:

**[3. Section 8 Tenant Based Assistance\--Section 8(y) Homeownership
Program]{.underline}**

(if applicable) \[24 CFR Part 903.12(c), 903.7(k)(1)(i)\]

1\. Yes No: Does the PHA plan to administer a Section 8 Homeownership
program pursuant to Section 8(y) of the U.S.H.A. of 1937, as implemented
by 24 CFR part 982 ? (If "No", skip to the next component; if "yes",
complete each program description below (copy and complete questions for
each program identified.)

2\. Program Description:

a\. Size of Program

Yes No: Will the PHA limit the number of families participating in the
Section 8 homeownership option?

> If the answer to the question above was yes, what is the maximum
> number of participants this fiscal year?

b\. PHA-established eligibility criteria

Yes No: Will the PHA's program have eligibility criteria for
participation in its Section 8 Homeownership Option program in addition
to HUD criteria?

> If yes, list criteria:

c\. What actions will the PHA undertake to implement the program this
year (list)?

3\. Capacity of the PHA to Administer a Section 8 Homeownership Program:

The PHA has demonstrated its capacity to administer the program by
(select all that apply):

Establishing a minimum homeowner downpayment requirement of at least 3
percent of purchase price and requiring that at least 1 percent of the
purchase price comes from the family's resources.

Requiring that financing for purchase of a home under its Section 8
homeownership will be provided, insured or guaranteed by the state or
Federal government; comply with secondary mortgage market underwriting
requirements; or comply with generally accepted private sector
underwriting standards.

Partnering with a qualified agency or agencies to administer the program
(list name(s) and years of experience below):

Demonstrating that it has other relevant experience (list experience
below):

**[4. Use of the Project-Based Voucher Program]{.underline}**

**Intent to Use Project-Based Assistance**

Yes No: Does the PHA plan to "project-base" any tenant-based Section 8
vouchers in the coming year? If the answer is "no," go to the next
component. If yes, answer the following questions.

1.   Yes No: Are there circumstances indicating that the project basing
    of the units, rather than tenant-basing of the same amount of
    assistance is an appropriate option? If yes, check which
    circumstances apply:

    low utilization rate for vouchers due to lack of suitable rental
    units

    access to neighborhoods outside of high poverty areas

    other (describe below:)

2.  Indicate the number of units and general location of units (e.g.
    eligible census tracts or smaller areas within eligible census
    tracts):

    **[5. PHA Statement of Consistency with the Consolidated
    Plan]{.underline}**

\[24 CFR Part 903.15\]

For each applicable Consolidated Plan, make the following statement
(copy questions as many times as necessary) only if the PHA has provided
a certification listing program or policy changes from its last Annual
Plan submission.

1\. Consolidated Plan jurisdiction: (provide name here)

2\. The PHA has taken the following steps to ensure consistency of this
PHA Plan with the Consolidated Plan for the jurisdiction: (select all
that apply)

The PHA has based its statement of needs of families on its waiting
lists on the needs expressed in the Consolidated Plan/s.

The PHA has participated in any consultation process organized and
offered by the Consolidated Plan agency in the development of the
Consolidated Plan.

The PHA has consulted with the Consolidated Plan agency during the
development of this PHA Plan.

Activities to be undertaken by the PHA in the coming year are consistent
with the initiatives contained in the Consolidated Plan. (list below)

Other: (list below)

3\. The Consolidated Plan of the jurisdiction supports the PHA Plan with
the following actions and commitments: (describe below)

### 

### [6. Supporting Documents Available for Review for Streamlined Annual PHA Plans]{.underline}

PHAs are to indicate which documents are available for public review by
placing a mark in the "Applicable & On Display" column in the
appropriate rows. All listed documents must be on display if applicable
to the program activities conducted by the PHA.

+--------+--------------------------------------------+----------------+
| #### L |                                            |                |
| ist of |                                            |                |
|  Suppo |                                            |                |
| rting  |                                            |                |
| Docume |                                            |                |
| nts Av |                                            |                |
| ailabl |                                            |                |
| e for  |                                            |                |
| Review |                                            |                |
+========+============================================+================+
| **Appl | ### Supporting Document                    | **Related Plan |
| icable |                                            | Component**    |
| & On   |                                            |                |
| Dis    |                                            |                |
| play** |                                            |                |
+--------+--------------------------------------------+----------------+
|        | *PHA Certifications of Compliance with the | 5 Year and     |
|        | PHA Plans and Related Regulations and      | Annual Plans   |
|        | Board Resolution to Accompany the Standard |                |
|        | Annual, Standard Five-Year, and            |                |
|        | Streamlined Five-Year/Annual Plans*;       |                |
+--------+--------------------------------------------+----------------+
|        | *PHA Certifications of Compliance with the | Streamlined    |
|        | PHA Plans and Related Regulations and      | Annual Plans   |
|        | Board Resolution to Accompany the          |                |
|        | Streamlined Annual Plan*                   |                |
+--------+--------------------------------------------+----------------+
|        | *Certification by State or Local Official  | 5 Year and     |
|        | of PHA Plan Consistency with Consolidated  | standard       |
|        | Plan*.                                     | Annual Plans   |
+--------+--------------------------------------------+----------------+
|        | Fair Housing Documentation Supporting Fair | 5 Year and     |
|        | Housing Certifications: Records reflecting | Annual Plans   |
|        | that the PHA has examined its programs or  |                |
|        | proposed programs, identified any          |                |
|        | impediments to fair housing choice in      |                |
|        | those programs, addressed or is addressing |                |
|        | those impediments in a reasonable fashion  |                |
|        | in view of the resources available, and    |                |
|        | worked or is working with local            |                |
|        | jurisdictions to implement any of the      |                |
|        | jurisdictions' initiatives to              |                |
|        | affirmatively further fair housing that    |                |
|        | require the PHA's involvement.             |                |
+--------+--------------------------------------------+----------------+
|        | Housing Needs Statement of the             | Annual Plan:   |
|        | Consolidated Plan for the jurisdiction(s)  |                |
|        | in which the PHA is located and any        | Housing Needs  |
|        | additional backup data to support          |                |
|        | statement of housing needs for families on |                |
|        | the PHA's public housing and Section 8     |                |
|        | tenant-based waiting lists.                |                |
+--------+--------------------------------------------+----------------+
|        | Most recent board-approved operating       | Annual Plan:   |
|        | budget for the public housing program      |                |
|        |                                            | Financial      |
|        |                                            | Resources      |
+--------+--------------------------------------------+----------------+
|        | Public Housing Admissions and (Continued)  | Annual Plan:   |
|        | Occupancy Policy (A&O/ACOP), which         | Eligibility,   |
|        | includes the Tenant Selection and          | Selection, and |
|        | Assignment Plan \[TSAP\] and the           | Admissions     |
|        | Site-Based Waiting List Procedure.         | Policies       |
+--------+--------------------------------------------+----------------+
|        | Deconcentration Income Analysis            | Annual Plan:   |
|        |                                            | Eligibility,   |
|        |                                            | Selection, and |
|        |                                            | Admissions     |
|        |                                            | Policies       |
+--------+--------------------------------------------+----------------+
|        | Any policy governing occupancy of Police   | Annual Plan:   |
|        | Officers and Over-Income Tenants in Public | Eligibility,   |
|        | Housing. Check here if included in the     | Selection, and |
|        | public housing A&O Policy.                 | Admissions     |
|        |                                            | Policies       |
+--------+--------------------------------------------+----------------+
|        | Section 8 Administrative Plan              | Annual Plan:   |
|        |                                            | Eligibility,   |
|        |                                            | Selection, and |
|        |                                            | Admissions     |
|        |                                            | Policies       |
+--------+--------------------------------------------+----------------+
|        | Public housing rent determination          | Annual Plan:   |
|        | policies, including the method for setting | Rent           |
|        | public housing flat rents.                 | Determination  |
|        |                                            |                |
|        | Check here if included in the public       |                |
|        | housing A & O Policy.                      |                |
+--------+--------------------------------------------+----------------+
|        | Schedule of flat rents offered at each     | Annual Plan:   |
|        | public housing development.                | Rent           |
|        |                                            | Determination  |
|        | Check here if included in the public       |                |
|        | housing A & O Policy.                      |                |
+--------+--------------------------------------------+----------------+
|        | Section 8 rent determination (payment      | Annual Plan:   |
|        | standard) policies (if included in plan,   | Rent           |
|        | not necessary as a supporting document)    | Determination  |
|        | and written analysis of Section 8 payment  |                |
|        | standard policies. Check here if included  |                |
|        | in Section 8 Administrative Plan.          |                |
+--------+--------------------------------------------+----------------+
|        | Public housing management and maintenance  | Annual Plan:   |
|        | policy documents, including policies for   | Operations and |
|        | the prevention or eradication of pest      | Maintenance    |
|        | infestation (including cockroach           |                |
|        | infestation).                              |                |
+--------+--------------------------------------------+----------------+
|        | Results of latest Public Housing           | Annual Plan:   |
|        | Assessment System (PHAS) Assessment (or    | Management and |
|        | other applicable assessment).              | Operations     |
+--------+--------------------------------------------+----------------+
|        | Follow-up Plan to Results of the PHAS      | Annual Plan:   |
|        | Resident Satisfaction Survey (if           | Operations and |
|        | necessary)                                 | Maintenance    |
|        |                                            | and Community  |
|        |                                            | Service &      |
|        |                                            | Se             |
|        |                                            | lf-Sufficiency |
+--------+--------------------------------------------+----------------+
|        | Results of latest Section 8 Management     | Annual Plan:   |
|        | Assessment System (SEMAP)                  | Management and |
|        |                                            | Operations     |
+--------+--------------------------------------------+----------------+
|        | Any policies governing any Section 8       | Annual Plan:   |
|        | special housing types                      | Operations and |
|        |                                            | Maintenance    |
|        | Check here if included in Section 8        |                |
|        | Administrative Plan                        |                |
+--------+--------------------------------------------+----------------+
|        | Public housing grievance procedures        | Annual Plan:   |
|        |                                            | Grievance      |
|        | Check here if included in the public       | Procedures     |
|        | housing A & O Policy                       |                |
+--------+--------------------------------------------+----------------+
|        | Section 8 informal review and hearing      | Annual Plan:   |
|        | procedures.                                | Grievance      |
|        |                                            | Procedures     |
|        | Check here if included in Section 8        |                |
|        | Administrative Plan.                       |                |
+--------+--------------------------------------------+----------------+
|        | The Capital Fund/Comprehensive Grant       | Annual Plan:   |
|        | Program Annual Statement /Performance and  | Capital Needs  |
|        | Evaluation Report for any active grant     |                |
|        | year.                                      |                |
+--------+--------------------------------------------+----------------+
|        | Most recent CIAP Budget/Progress Report    | Annual Plan:   |
|        | (HUD 52825) for any active CIAP grants.    | Capital Needs  |
+--------+--------------------------------------------+----------------+
|        | Approved HOPE VI applications or, if more  | Annual Plan:   |
|        | recent, approved or submitted HOPE VI      | Capital Needs  |
|        | Revitalization Plans, or any other         |                |
|        | approved proposal for development of       |                |
|        | public housing.                            |                |
+--------+--------------------------------------------+----------------+
|        | Self-evaluation, Needs Assessment and      | Annual Plan:   |
|        | Transition Plan required by regulations    | Capital Needs  |
|        | implementing Section 504 of the            |                |
|        | Rehabilitation Act and the Americans with  |                |
|        | Disabilities Act. See PIH Notice 99-52     |                |
|        | (HA).                                      |                |
+--------+--------------------------------------------+----------------+
|        | Approved or submitted applications for     | Annual Plan:   |
|        | demolition and/or disposition of public    | Demolition and |
|        | housing.                                   | Disposition    |
+--------+--------------------------------------------+----------------+
|        | Approved or submitted applications for     | Annual Plan:   |
|        | designation of public housing (Designated  | Designation of |
|        | Housing Plans).                            | Public Housing |
+--------+--------------------------------------------+----------------+
|        | Approved or submitted assessments of       | Annual Plan:   |
|        | reasonable revitalization of public        | Conversion of  |
|        | housing and approved or submitted          | Public Housing |
|        | conversion plans prepared pursuant to      |                |
|        | section 202 of the 1996 HUD Appropriations |                |
|        | Act, Section 22 of the US Housing Act of   |                |
|        | 1937, or Section 33 of the US Housing Act  |                |
|        | of 1937.                                   |                |
+--------+--------------------------------------------+----------------+
|        | Documentation for required Initial         | Annual Plan:   |
|        | Assessment and any additional information  | Voluntary      |
|        | required by HUD for Voluntary Conversion.  | Conversion of  |
|        |                                            | Public Housing |
+--------+--------------------------------------------+----------------+
|        | Approved or submitted public housing       | Annual Plan:   |
|        | homeownership programs/plans.              | Homeownership  |
+--------+--------------------------------------------+----------------+
|        | Policies governing any Section 8           | Annual Plan:   |
|        | Homeownership program                      | Homeownership  |
|        |                                            |                |
|        | (Section \_\_\_\_\_\_of the Section 8      |                |
|        | Administrative Plan)                       |                |
+--------+--------------------------------------------+----------------+
|        | Public Housing Community Service           | Annual Plan:   |
|        | Policy/Programs                            | Community      |
|        |                                            | Service &      |
|        | Check here if included in Public Housing A | Se             |
|        | & O Policy                                 | lf-Sufficiency |
+--------+--------------------------------------------+----------------+
|        | Cooperative agreement between the PHA and  | Annual Plan:   |
|        | the TANF agency and between the PHA and    | Community      |
|        | local employment and training service      | Service &      |
|        | agencies.                                  | Se             |
|        |                                            | lf-Sufficiency |
+--------+--------------------------------------------+----------------+
|        | FSS Action Plan(s) for public housing      | Annual Plan:   |
|        | and/or Section 8.                          | Community      |
|        |                                            | Service &      |
|        |                                            | Se             |
|        |                                            | lf-Sufficiency |
+--------+--------------------------------------------+----------------+
|        | Section 3 documentation required by 24 CFR | Annual Plan:   |
|        | Part 135, Subpart E for public housing.    | Community      |
|        |                                            | Service &      |
|        |                                            | Se             |
|        |                                            | lf-Sufficiency |
+--------+--------------------------------------------+----------------+
|        | Most recent self-sufficiency (ED/SS, TOP   | Annual Plan:   |
|        | or ROSS or other resident services grant)  | Community      |
|        | grant program reports for public housing.  | Service &      |
|        |                                            | Se             |
|        |                                            | lf-Sufficiency |
+--------+--------------------------------------------+----------------+
|        | Policy on Ownership of Pets in Public      | Annual Plan:   |
|        | Housing Family Developments (as required   | Pet Policy     |
|        | by regulation at 24 CFR Part 960, Subpart  |                |
|        | G).                                        |                |
|        |                                            |                |
|        | Check here if included in the public       |                |
|        | housing A & O Policy.                      |                |
+--------+--------------------------------------------+----------------+
|        | The results of the most recent fiscal year | Annual Plan:   |
|        | audit of the PHA conducted under the       | Annual Audit   |
|        | Single Audit Act as implemented by OMB     |                |
|        | Circular A-133, the results of that audit  |                |
|        | and the PHA's response to any findings.    |                |
+--------+--------------------------------------------+----------------+
|        | Other supporting documents (optional)      | (specify as    |
|        |                                            | needed)        |
|        | (list individually; use as many lines as   |                |
|        | necessary)                                 |                |
+--------+--------------------------------------------+----------------+
|        | Consortium agreement(s) and for Consortium | Joint Annual   |
|        | Joint PHA Plans [Only]{.underline}:        | PHA Plan for   |
|        | Certification that consortium agreement is | Consortia:     |
|        | in compliance with 24 CFR Part 943         | Agency         |
|        | pursuant to an opinion of counsel on file  | Identification |
|        | and available for inspection.              | and Annual     |
|        |                                            | Management and |
|        |                                            | Operations     |
+--------+--------------------------------------------+----------------+

+-----------+--------------------+---+-------+-------+--------+---+-----+
| **Annual  |                    |   |       |       |        |   |     |
| Sta       |                    |   |       |       |        |   |     |
| tement/Pe |                    |   |       |       |        |   |     |
| rformance |                    |   |       |       |        |   |     |
| and       |                    |   |       |       |        |   |     |
| E         |                    |   |       |       |        |   |     |
| valuation |                    |   |       |       |        |   |     |
| Report**  |                    |   |       |       |        |   |     |
|           |                    |   |       |       |        |   |     |
| **Capital |                    |   |       |       |        |   |     |
| Fund      |                    |   |       |       |        |   |     |
| Program   |                    |   |       |       |        |   |     |
| and       |                    |   |       |       |        |   |     |
| Capital   |                    |   |       |       |        |   |     |
| Fund      |                    |   |       |       |        |   |     |
| Program   |                    |   |       |       |        |   |     |
| Re        |                    |   |       |       |        |   |     |
| placement |                    |   |       |       |        |   |     |
| Housing   |                    |   |       |       |        |   |     |
| Factor    |                    |   |       |       |        |   |     |
| (CF       |                    |   |       |       |        |   |     |
| P/CFPRHF) |                    |   |       |       |        |   |     |
| Part I:   |                    |   |       |       |        |   |     |
| Summary** |                    |   |       |       |        |   |     |
+===========+====================+===+=======+=======+========+===+=====+
| **PHA     |                    | * |       |       |        |   | **F |
| Name:**   |                    | * |       |       |        |   | ede |
|           |                    | G |       |       |        |   | ral |
|           |                    | r |       |       |        |   | FY  |
|           |                    | a |       |       |        |   | of  |
|           |                    | n |       |       |        |   | Gr  |
|           |                    | t |       |       |        |   | ant |
|           |                    | T |       |       |        |   | :** |
|           |                    | y |       |       |        |   |     |
|           |                    | p |       |       |        |   |     |
|           |                    | e |       |       |        |   |     |
|           |                    | a |       |       |        |   |     |
|           |                    | n |       |       |        |   |     |
|           |                    | d |       |       |        |   |     |
|           |                    | N |       |       |        |   |     |
|           |                    | u |       |       |        |   |     |
|           |                    | m |       |       |        |   |     |
|           |                    | b |       |       |        |   |     |
|           |                    | e |       |       |        |   |     |
|           |                    | r |       |       |        |   |     |
|           |                    | * |       |       |        |   |     |
|           |                    | * |       |       |        |   |     |
|           |                    |   |       |       |        |   |     |
|           |                    | C |       |       |        |   |     |
|           |                    | a |       |       |        |   |     |
|           |                    | p |       |       |        |   |     |
|           |                    | i |       |       |        |   |     |
|           |                    | t |       |       |        |   |     |
|           |                    | a |       |       |        |   |     |
|           |                    | l |       |       |        |   |     |
|           |                    | F |       |       |        |   |     |
|           |                    | u |       |       |        |   |     |
|           |                    | n |       |       |        |   |     |
|           |                    | d |       |       |        |   |     |
|           |                    | P |       |       |        |   |     |
|           |                    | r |       |       |        |   |     |
|           |                    | o |       |       |        |   |     |
|           |                    | g |       |       |        |   |     |
|           |                    | r |       |       |        |   |     |
|           |                    | a |       |       |        |   |     |
|           |                    | m |       |       |        |   |     |
|           |                    | G |       |       |        |   |     |
|           |                    | r |       |       |        |   |     |
|           |                    | a |       |       |        |   |     |
|           |                    | n |       |       |        |   |     |
|           |                    | t |       |       |        |   |     |
|           |                    | N |       |       |        |   |     |
|           |                    | o |       |       |        |   |     |
|           |                    | : |       |       |        |   |     |
|           |                    |   |       |       |        |   |     |
|           |                    | R |       |       |        |   |     |
|           |                    | e |       |       |        |   |     |
|           |                    | p |       |       |        |   |     |
|           |                    | l |       |       |        |   |     |
|           |                    | a |       |       |        |   |     |
|           |                    | c |       |       |        |   |     |
|           |                    | e |       |       |        |   |     |
|           |                    | m |       |       |        |   |     |
|           |                    | e |       |       |        |   |     |
|           |                    | n |       |       |        |   |     |
|           |                    | t |       |       |        |   |     |
|           |                    | H |       |       |        |   |     |
|           |                    | o |       |       |        |   |     |
|           |                    | u |       |       |        |   |     |
|           |                    | s |       |       |        |   |     |
|           |                    | i |       |       |        |   |     |
|           |                    | n |       |       |        |   |     |
|           |                    | g |       |       |        |   |     |
|           |                    | F |       |       |        |   |     |
|           |                    | a |       |       |        |   |     |
|           |                    | c |       |       |        |   |     |
|           |                    | t |       |       |        |   |     |
|           |                    | o |       |       |        |   |     |
|           |                    | r |       |       |        |   |     |
|           |                    | G |       |       |        |   |     |
|           |                    | r |       |       |        |   |     |
|           |                    | a |       |       |        |   |     |
|           |                    | n |       |       |        |   |     |
|           |                    | t |       |       |        |   |     |
|           |                    | N |       |       |        |   |     |
|           |                    | o |       |       |        |   |     |
|           |                    | : |       |       |        |   |     |
+-----------+--------------------+---+-------+-------+--------+---+-----+
| *         |                    |   |       |       |        |   |     |
| *Original |                    |   |       |       |        |   |     |
| Annual    |                    |   |       |       |        |   |     |
| St        |                    |   |       |       |        |   |     |
| atement** |                    |   |       |       |        |   |     |
| **Reserve |                    |   |       |       |        |   |     |
| for       |                    |   |       |       |        |   |     |
| D         |                    |   |       |       |        |   |     |
| isasters/ |                    |   |       |       |        |   |     |
| Emer      |                    |   |       |       |        |   |     |
| gencies** |                    |   |       |       |        |   |     |
| **Revised |                    |   |       |       |        |   |     |
| Annual    |                    |   |       |       |        |   |     |
| Statement |                    |   |       |       |        |   |     |
| (revision |                    |   |       |       |        |   |     |
| no:** )   |                    |   |       |       |        |   |     |
|           |                    |   |       |       |        |   |     |
| **Pe      |                    |   |       |       |        |   |     |
| rformance |                    |   |       |       |        |   |     |
| and       |                    |   |       |       |        |   |     |
| E         |                    |   |       |       |        |   |     |
| valuation |                    |   |       |       |        |   |     |
| Report    |                    |   |       |       |        |   |     |
| for       |                    |   |       |       |        |   |     |
| Period    |                    |   |       |       |        |   |     |
| Ending:** |                    |   |       |       |        |   |     |
| **Final   |                    |   |       |       |        |   |     |
| Pe        |                    |   |       |       |        |   |     |
| rformance |                    |   |       |       |        |   |     |
| and       |                    |   |       |       |        |   |     |
| E         |                    |   |       |       |        |   |     |
| valuation |                    |   |       |       |        |   |     |
| Report**  |                    |   |       |       |        |   |     |
+-----------+--------------------+---+-------+-------+--------+---+-----+
| **Line    | **Summary by       |   | **    |       | *      |   |     |
| No.**     | Development        |   | Total |       | *Total |   |     |
|           | Account**          |   | Esti  |       | Actual |   |     |
|           |                    |   | mated |       | Cost** |   |     |
|           |                    |   | C     |       |        |   |     |
|           |                    |   | ost** |       |        |   |     |
+-----------+--------------------+---+-------+-------+--------+---+-----+
|           |                    |   | **    | *     | *      | * |     |
|           |                    |   | Origi | *Revi | *Oblig | * |     |
|           |                    |   | nal** | sed** | ated** | E |     |
|           |                    |   |       |       |        | x |     |
|           |                    |   |       |       |        | p |     |
|           |                    |   |       |       |        | e |     |
|           |                    |   |       |       |        | n |     |
|           |                    |   |       |       |        | d |     |
|           |                    |   |       |       |        | e |     |
|           |                    |   |       |       |        | d |     |
|           |                    |   |       |       |        | * |     |
|           |                    |   |       |       |        | * |     |
+-----------+--------------------+---+-------+-------+--------+---+-----+
| 1         | Total non-CFP      |   |       |       |        |   |     |
|           | Funds              |   |       |       |        |   |     |
+-----------+--------------------+---+-------+-------+--------+---+-----+
| 2         | 1406 Operations    |   |       |       |        |   |     |
+-----------+--------------------+---+-------+-------+--------+---+-----+
| 3         | 1408 Management    |   |       |       |        |   |     |
|           | Improvements       |   |       |       |        |   |     |
+-----------+--------------------+---+-------+-------+--------+---+-----+
| 4         | 1410               |   |       |       |        |   |     |
|           | Administration     |   |       |       |        |   |     |
+-----------+--------------------+---+-------+-------+--------+---+-----+
| 5         | 1411 Audit         |   |       |       |        |   |     |
+-----------+--------------------+---+-------+-------+--------+---+-----+
| 6         | 1415 Liquidated    |   |       |       |        |   |     |
|           | Damages            |   |       |       |        |   |     |
+-----------+--------------------+---+-------+-------+--------+---+-----+
| 7         | 1430 Fees and      |   |       |       |        |   |     |
|           | Costs              |   |       |       |        |   |     |
+-----------+--------------------+---+-------+-------+--------+---+-----+
| 8         | 1440 Site          |   |       |       |        |   |     |
|           | Acquisition        |   |       |       |        |   |     |
+-----------+--------------------+---+-------+-------+--------+---+-----+
| 9         | 1450 Site          |   |       |       |        |   |     |
|           | Improvement        |   |       |       |        |   |     |
+-----------+--------------------+---+-------+-------+--------+---+-----+
| 10        | 1460 Dwelling      |   |       |       |        |   |     |
|           | Structures         |   |       |       |        |   |     |
+-----------+--------------------+---+-------+-------+--------+---+-----+
| 11        | 1465.1 Dwelling    |   |       |       |        |   |     |
|           | Equipme            |   |       |       |        |   |     |
|           | nt---Nonexpendable |   |       |       |        |   |     |
+-----------+--------------------+---+-------+-------+--------+---+-----+
| 12        | 1470 Nondwelling   |   |       |       |        |   |     |
|           | Structures         |   |       |       |        |   |     |
+-----------+--------------------+---+-------+-------+--------+---+-----+
| 13        | 1475 Nondwelling   |   |       |       |        |   |     |
|           | Equipment          |   |       |       |        |   |     |
+-----------+--------------------+---+-------+-------+--------+---+-----+
| 14        | 1485 Demolition    |   |       |       |        |   |     |
+-----------+--------------------+---+-------+-------+--------+---+-----+
| 15        | 1490 Replacement   |   |       |       |        |   |     |
|           | Reserve            |   |       |       |        |   |     |
+-----------+--------------------+---+-------+-------+--------+---+-----+
| 16        | 1492 Moving to     |   |       |       |        |   |     |
|           | Work Demonstration |   |       |       |        |   |     |
+-----------+--------------------+---+-------+-------+--------+---+-----+
| 17        | 1495.1 Relocation  |   |       |       |        |   |     |
|           | Costs              |   |       |       |        |   |     |
+-----------+--------------------+---+-------+-------+--------+---+-----+
| 18        | 1499 Development   |   |       |       |        |   |     |
|           | Activities         |   |       |       |        |   |     |
+-----------+--------------------+---+-------+-------+--------+---+-----+
| 19        | 1501               |   |       |       |        |   |     |
|           | Collaterization or |   |       |       |        |   |     |
|           | Debt Service       |   |       |       |        |   |     |
+-----------+--------------------+---+-------+-------+--------+---+-----+
| 20        | 1502 Contingency   |   |       |       |        |   |     |
+-----------+--------------------+---+-------+-------+--------+---+-----+
| 21        | Amount of Annual   |   |       |       |        |   |     |
|           | Grant: (sum of     |   |       |       |        |   |     |
|           | lines 2 -- 20)     |   |       |       |        |   |     |
+-----------+--------------------+---+-------+-------+--------+---+-----+
| 22        | Amount of line 21  |   |       |       |        |   |     |
|           | Related to LBP     |   |       |       |        |   |     |
|           | Activities         |   |       |       |        |   |     |
+-----------+--------------------+---+-------+-------+--------+---+-----+
| 23        | Amount of line 21  |   |       |       |        |   |     |
|           | Related to Section |   |       |       |        |   |     |
|           | 504 compliance     |   |       |       |        |   |     |
+-----------+--------------------+---+-------+-------+--------+---+-----+
| 24        | Amount of line 21  |   |       |       |        |   |     |
|           | Related to         |   |       |       |        |   |     |
|           | Security -- Soft   |   |       |       |        |   |     |
|           | Costs              |   |       |       |        |   |     |
+-----------+--------------------+---+-------+-------+--------+---+-----+
| 25        | Amount of Line 21  |   |       |       |        |   |     |
|           | Related to         |   |       |       |        |   |     |
|           | Security -- Hard   |   |       |       |        |   |     |
|           | Costs              |   |       |       |        |   |     |
+-----------+--------------------+---+-------+-------+--------+---+-----+
| 26        | Amount of line 21  |   |       |       |        |   |     |
|           | Related to Energy  |   |       |       |        |   |     |
|           | Conservation       |   |       |       |        |   |     |
|           | Measures           |   |       |       |        |   |     |
+-----------+--------------------+---+-------+-------+--------+---+-----+

<table>
<colgroup>
<col style="width: 12%" />
<col style="width: 19%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 9%" />
<col style="width: 9%" />
<col style="width: 10%" />
<col style="width: 11%" />
<col style="width: 10%" />
<col style="width: 8%" />
</colgroup>
<thead>
<tr class="header">
<th colspan="10"><p><strong>Annual Statement/Performance and Evaluation
Report</strong></p>
<p><strong>Capital Fund Program and Capital Fund Program Replacement
Housing Factor (CFP/CFPRHF)</strong></p>
<p><strong>Part II: Supporting Pages</strong></p></th>
</tr>
<tr class="odd">
<th colspan="2">PHA Name:</th>
<th colspan="5"><p><strong>Grant Type and Number</strong></p>
<p>Capital Fund Program Grant No:</p>
<p>Replacement Housing Factor Grant No:</p></th>
<th colspan="3"><strong>Federal FY of Grant:</strong></th>
</tr>
<tr class="header">
<th><p>Development Number</p>
<p>Name/HA-Wide Activities</p></th>
<th>General Description of Major Work Categories</th>
<th colspan="2">Dev. Acct No.</th>
<th>Quantity</th>
<th colspan="2">Total Estimated Cost</th>
<th colspan="2">Total Actual Cost</th>
<th>Status of Work</th>
</tr>
<tr class="odd">
<th></th>
<th></th>
<th colspan="2"></th>
<th></th>
<th>Original</th>
<th>Revised</th>
<th>Funds Obligated</th>
<th>Funds Expended</th>
<th></th>
</tr>
</thead>
<tbody>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>

+-----------+-----+---+---+----+------+-------+-----+------------------+
| **Annual  |     |   |   |    |      |       |     |                  |
| Sta       |     |   |   |    |      |       |     |                  |
| tement/Pe |     |   |   |    |      |       |     |                  |
| rformance |     |   |   |    |      |       |     |                  |
| and       |     |   |   |    |      |       |     |                  |
| E         |     |   |   |    |      |       |     |                  |
| valuation |     |   |   |    |      |       |     |                  |
| Report**  |     |   |   |    |      |       |     |                  |
|           |     |   |   |    |      |       |     |                  |
| **Capital |     |   |   |    |      |       |     |                  |
| Fund      |     |   |   |    |      |       |     |                  |
| Program   |     |   |   |    |      |       |     |                  |
| and       |     |   |   |    |      |       |     |                  |
| Capital   |     |   |   |    |      |       |     |                  |
| Fund      |     |   |   |    |      |       |     |                  |
| Program   |     |   |   |    |      |       |     |                  |
| Re        |     |   |   |    |      |       |     |                  |
| placement |     |   |   |    |      |       |     |                  |
| Housing   |     |   |   |    |      |       |     |                  |
| Factor    |     |   |   |    |      |       |     |                  |
| (CFP/     |     |   |   |    |      |       |     |                  |
| CFPRHF)** |     |   |   |    |      |       |     |                  |
|           |     |   |   |    |      |       |     |                  |
| **Part    |     |   |   |    |      |       |     |                  |
| III:      |     |   |   |    |      |       |     |                  |
| Imple     |     |   |   |    |      |       |     |                  |
| mentation |     |   |   |    |      |       |     |                  |
| S         |     |   |   |    |      |       |     |                  |
| chedule** |     |   |   |    |      |       |     |                  |
+===========+=====+===+===+====+======+=======+=====+==================+
| PHA Name: |     |   | * |    |      |       |     | **Federal FY of  |
|           |     |   | * |    |      |       |     | Grant:**         |
|           |     |   | G |    |      |       |     |                  |
|           |     |   | r |    |      |       |     |                  |
|           |     |   | a |    |      |       |     |                  |
|           |     |   | n |    |      |       |     |                  |
|           |     |   | t |    |      |       |     |                  |
|           |     |   | T |    |      |       |     |                  |
|           |     |   | y |    |      |       |     |                  |
|           |     |   | p |    |      |       |     |                  |
|           |     |   | e |    |      |       |     |                  |
|           |     |   | a |    |      |       |     |                  |
|           |     |   | n |    |      |       |     |                  |
|           |     |   | d |    |      |       |     |                  |
|           |     |   | N |    |      |       |     |                  |
|           |     |   | u |    |      |       |     |                  |
|           |     |   | m |    |      |       |     |                  |
|           |     |   | b |    |      |       |     |                  |
|           |     |   | e |    |      |       |     |                  |
|           |     |   | r |    |      |       |     |                  |
|           |     |   | * |    |      |       |     |                  |
|           |     |   | * |    |      |       |     |                  |
|           |     |   |   |    |      |       |     |                  |
|           |     |   | C |    |      |       |     |                  |
|           |     |   | a |    |      |       |     |                  |
|           |     |   | p |    |      |       |     |                  |
|           |     |   | i |    |      |       |     |                  |
|           |     |   | t |    |      |       |     |                  |
|           |     |   | a |    |      |       |     |                  |
|           |     |   | l |    |      |       |     |                  |
|           |     |   | F |    |      |       |     |                  |
|           |     |   | u |    |      |       |     |                  |
|           |     |   | n |    |      |       |     |                  |
|           |     |   | d |    |      |       |     |                  |
|           |     |   | P |    |      |       |     |                  |
|           |     |   | r |    |      |       |     |                  |
|           |     |   | o |    |      |       |     |                  |
|           |     |   | g |    |      |       |     |                  |
|           |     |   | r |    |      |       |     |                  |
|           |     |   | a |    |      |       |     |                  |
|           |     |   | m |    |      |       |     |                  |
|           |     |   | N |    |      |       |     |                  |
|           |     |   | o |    |      |       |     |                  |
|           |     |   | : |    |      |       |     |                  |
|           |     |   |   |    |      |       |     |                  |
|           |     |   | R |    |      |       |     |                  |
|           |     |   | e |    |      |       |     |                  |
|           |     |   | p |    |      |       |     |                  |
|           |     |   | l |    |      |       |     |                  |
|           |     |   | a |    |      |       |     |                  |
|           |     |   | c |    |      |       |     |                  |
|           |     |   | e |    |      |       |     |                  |
|           |     |   | m |    |      |       |     |                  |
|           |     |   | e |    |      |       |     |                  |
|           |     |   | n |    |      |       |     |                  |
|           |     |   | t |    |      |       |     |                  |
|           |     |   | H |    |      |       |     |                  |
|           |     |   | o |    |      |       |     |                  |
|           |     |   | u |    |      |       |     |                  |
|           |     |   | s |    |      |       |     |                  |
|           |     |   | i |    |      |       |     |                  |
|           |     |   | n |    |      |       |     |                  |
|           |     |   | g |    |      |       |     |                  |
|           |     |   | F |    |      |       |     |                  |
|           |     |   | a |    |      |       |     |                  |
|           |     |   | c |    |      |       |     |                  |
|           |     |   | t |    |      |       |     |                  |
|           |     |   | o |    |      |       |     |                  |
|           |     |   | r |    |      |       |     |                  |
|           |     |   | N |    |      |       |     |                  |
|           |     |   | o |    |      |       |     |                  |
|           |     |   | : |    |      |       |     |                  |
+-----------+-----+---+---+----+------+-------+-----+------------------+
| De        | All |   |   |    | All  |       |     | Reasons for      |
| velopment | F   |   |   |    | F    |       |     | Revised Target   |
| Number    | und |   |   |    | unds |       |     | Dates            |
|           | Obl |   |   |    | Expe |       |     |                  |
| Nam       | iga |   |   |    | nded |       |     |                  |
| e/HA-Wide | ted |   |   |    |      |       |     |                  |
| A         |     |   |   |    | (Qua |       |     |                  |
| ctivities | (Q  |   |   |    | rter |       |     |                  |
|           | uar |   |   |    | En   |       |     |                  |
|           | ter |   |   |    | ding |       |     |                  |
|           | End |   |   |    | D    |       |     |                  |
|           | ing |   |   |    | ate) |       |     |                  |
|           | Da  |   |   |    |      |       |     |                  |
|           | te) |   |   |    |      |       |     |                  |
+-----------+-----+---+---+----+------+-------+-----+------------------+
|           | Or  | R |   | Ac | Orig | Re    | Act |                  |
|           | igi | e |   | tu | inal | vised | ual |                  |
|           | nal | v |   | al |      |       |     |                  |
|           |     | i |   |    |      |       |     |                  |
|           |     | s |   |    |      |       |     |                  |
|           |     | e |   |    |      |       |     |                  |
|           |     | d |   |    |      |       |     |                  |
+-----------+-----+---+---+----+------+-------+-----+------------------+
|           |     |   |   |    |      |       |     |                  |
+-----------+-----+---+---+----+------+-------+-----+------------------+
|           |     |   |   |    |      |       |     |                  |
+-----------+-----+---+---+----+------+-------+-----+------------------+
|           |     |   |   |    |      |       |     |                  |
+-----------+-----+---+---+----+------+-------+-----+------------------+
|           |     |   |   |    |      |       |     |                  |
+-----------+-----+---+---+----+------+-------+-----+------------------+
|           |     |   |   |    |      |       |     |                  |
+-----------+-----+---+---+----+------+-------+-----+------------------+
|           |     |   |   |    |      |       |     |                  |
+-----------+-----+---+---+----+------+-------+-----+------------------+
|           |     |   |   |    |      |       |     |                  |
+-----------+-----+---+---+----+------+-------+-----+------------------+
|           |     |   |   |    |      |       |     |                  |
+-----------+-----+---+---+----+------+-------+-----+------------------+
|           |     |   |   |    |      |       |     |                  |
+-----------+-----+---+---+----+------+-------+-----+------------------+
|           |     |   |   |    |      |       |     |                  |
+-----------+-----+---+---+----+------+-------+-----+------------------+
|           |     |   |   |    |      |       |     |                  |
+-----------+-----+---+---+----+------+-------+-----+------------------+
|           |     |   |   |    |      |       |     |                  |
+-----------+-----+---+---+----+------+-------+-----+------------------+
|           |     |   |   |    |      |       |     |                  |
+-----------+-----+---+---+----+------+-------+-----+------------------+
|           |     |   |   |    |      |       |     |                  |
+-----------+-----+---+---+----+------+-------+-----+------------------+

+---------+-----+------------+--------------+-------------+----------+
| ##      |     |            |              |             |          |
| ######  |     |            |              |             |          |
| Capital |     |            |              |             |          |
|  Fund P |     |            |              |             |          |
| rogram  |     |            |              |             |          |
| Five-Ye |     |            |              |             |          |
| ar Acti |     |            |              |             |          |
| on Plan |     |            |              |             |          |
|         |     |            |              |             |          |
| ####### |     |            |              |             |          |
|  **Part |     |            |              |             |          |
|  I: Sum |     |            |              |             |          |
| mary**  |     |            |              |             |          |
+---------+-----+------------+--------------+-------------+----------+
| PHA     |     |            |              | **Original  |          |
| Name    |     |            |              | 5-Year      |          |
|         |     |            |              | Plan**      |          |
|         |     |            |              |             |          |
|         |     |            |              | **Revision  |          |
|         |     |            |              | No:**       |          |
+---------+-----+------------+--------------+-------------+----------+
| Deve    | Y   | Work       | Work         | Work        | Work     |
| lopment | ear | Statement  | Statement    | Statement   | S        |
| Numbe   | 1   |            |              |             | tatement |
| r/Name/ |     | for Year 2 | for Year 3   | for Year 4  | for Year |
|         |     |            |              |             | 5        |
| HA-Wide |     | FFY Grant: | FFY Grant:   | FFY Grant:  |          |
|         |     |            |              |             | FFY      |
|         |     | PHA FY:    | PHA FY:      | PHA FY:     | Grant:   |
|         |     |            |              |             |          |
|         |     |            |              |             | PHA FY:  |
+---------+-----+------------+--------------+-------------+----------+
| #       | Ann |            |              |             |          |
|         | ual |            |              |             |          |
| #       |     |            |              |             |          |
|         | Sta |            |              |             |          |
|         | tem |            |              |             |          |
|         | ent |            |              |             |          |
+---------+-----+------------+--------------+-------------+----------+
|         |     |            |              |             |          |
+---------+-----+------------+--------------+-------------+----------+
|         |     |            |              |             |          |
+---------+-----+------------+--------------+-------------+----------+
|         |     |            |              |             |          |
+---------+-----+------------+--------------+-------------+----------+
|         |     |            |              |             |          |
+---------+-----+------------+--------------+-------------+----------+
|         |     |            |              |             |          |
+---------+-----+------------+--------------+-------------+----------+
|         |     |            |              |             |          |
+---------+-----+------------+--------------+-------------+----------+
|         |     |            |              |             |          |
+---------+-----+------------+--------------+-------------+----------+
|         |     |            |              |             |          |
+---------+-----+------------+--------------+-------------+----------+
|         |     |            |              |             |          |
+---------+-----+------------+--------------+-------------+----------+
| CFP     |     |            |              |             |          |
| Funds   |     |            |              |             |          |
| Listed  |     |            |              |             |          |
| for     |     |            |              |             |          |
| 5-year  |     |            |              |             |          |
| p       |     |            |              |             |          |
| lanning |     |            |              |             |          |
+---------+-----+------------+--------------+-------------+----------+
|         |     |            |              |             |          |
+---------+-----+------------+--------------+-------------+----------+
| Repl    |     |            |              |             |          |
| acement |     |            |              |             |          |
| Housing |     |            |              |             |          |
| Factor  |     |            |              |             |          |
| Funds   |     |            |              |             |          |
+---------+-----+------------+--------------+-------------+----------+

+------+-----------+---------+---------+----------+---------+--------+
| ##   |           |         |         |          |         |        |
| #### |           |         |         |          |         |        |
| # ** |           |         |         |          |         |        |
| Capi |           |         |         |          |         |        |
| tal  |           |         |         |          |         |        |
| Fund |           |         |         |          |         |        |
|  Pro |           |         |         |          |         |        |
| gram |           |         |         |          |         |        |
|  Fiv |           |         |         |          |         |        |
| e-Ye |           |         |         |          |         |        |
| ar A |           |         |         |          |         |        |
| ctio |           |         |         |          |         |        |
| n Pl |           |         |         |          |         |        |
| an** |           |         |         |          |         |        |
|      |           |         |         |          |         |        |
| **   |           |         |         |          |         |        |
| Part |           |         |         |          |         |        |
| II:  |           |         |         |          |         |        |
| Su   |           |         |         |          |         |        |
| ppor |           |         |         |          |         |        |
| ting |           |         |         |          |         |        |
| Page |           |         |         |          |         |        |
| s--- |           |         |         |          |         |        |
| Work |           |         |         |          |         |        |
| Acti |           |         |         |          |         |        |
| viti |           |         |         |          |         |        |
| es** |           |         |         |          |         |        |
+------+-----------+---------+---------+----------+---------+--------+
| Ac   | A         |         |         | Ac       |         |        |
| tivi | ctivities |         |         | tivities |         |        |
| ties | for Year  |         |         | for      |         |        |
| for  | :\_\_­\_\_ |         |         | Year:    |         |        |
|      |           |         |         | \_\_\_   |         |        |
| Year | FFY       |         |         |          |         |        |
| 1    | Grant:    |         |         | FFY      |         |        |
|      |           |         |         | Grant:   |         |        |
|      | PHA FY:   |         |         |          |         |        |
|      |           |         |         | PHA FY:  |         |        |
+------+-----------+---------+---------+----------+---------+--------+
| ##   | **De      | **Major | ## **Es | **Dev    | **Major | **Est  |
|      | velopment | Work    | timated | elopment | Work    | imated |
|      | Name      | Categ   |  Cost** | Name/    | Categ   | Cost** |
|      | /Number** | ories** |         | Number** | ories** |        |
+------+-----------+---------+---------+----------+---------+--------+
| ##   | ####      | ###     |         | #####    | #       |        |
|  **S |           |         |         |          |         |        |
| ee** |           |         |         |          |         |        |
+------+-----------+---------+---------+----------+---------+--------+
| #    |           | #       |         |          | ####    |        |
| # ** |           |         |         |          |         |        |
| Annu |           |         |         |          |         |        |
| al** |           |         |         |          |         |        |
+------+-----------+---------+---------+----------+---------+--------+
| *    | ####      |         |         | ####     | ####    |        |
| *Sta |           |         |         |          |         |        |
| teme |           |         |         |          |         |        |
| nt** |           |         |         |          |         |        |
+------+-----------+---------+---------+----------+---------+--------+
|      |           |         |         |          |         |        |
+------+-----------+---------+---------+----------+---------+--------+
|      |           |         |         |          |         |        |
+------+-----------+---------+---------+----------+---------+--------+
|      |           |         |         |          |         |        |
+------+-----------+---------+---------+----------+---------+--------+
|      |           |         |         |          |         |        |
+------+-----------+---------+---------+----------+---------+--------+
|      |           |         |         |          |         |        |
+------+-----------+---------+---------+----------+---------+--------+
|      |           |         |         |          |         |        |
+------+-----------+---------+---------+----------+---------+--------+
|      |           |         |         |          |         |        |
+------+-----------+---------+---------+----------+---------+--------+
|      |           |         |         |          |         |        |
+------+-----------+---------+---------+----------+---------+--------+
|      |           |         |         |          |         |        |
+------+-----------+---------+---------+----------+---------+--------+
|      |           |         |         |          |         |        |
+------+-----------+---------+---------+----------+---------+--------+
|      |           |         |         |          |         |        |
+------+-----------+---------+---------+----------+---------+--------+
|      |           |         |         |          |         |        |
+------+-----------+---------+---------+----------+---------+--------+
|      |           |         |         |          |         |        |
+------+-----------+---------+---------+----------+---------+--------+
|      |           |         |         |          |         |        |
+------+-----------+---------+---------+----------+---------+--------+
| #### |           |         | \$      |          |         | \$     |
| ## T |           |         |         |          |         |        |
| otal |           |         |         |          |         |        |
|  CFP |           |         |         |          |         |        |
|  Est |           |         |         |          |         |        |
| imat |           |         |         |          |         |        |
| ed C |           |         |         |          |         |        |
| ost  |           |         |         |          |         |        |
+------+-----------+---------+---------+----------+---------+--------+

+-----------+----------+-----------+-----------+--------+-----------+
| ####### * |          |           |           |        |           |
| *Capital  |          |           |           |        |           |
| Fund Prog |          |           |           |        |           |
| ram Five- |          |           |           |        |           |
| Year Acti |          |           |           |        |           |
| on Plan** |          |           |           |        |           |
|           |          |           |           |        |           |
| ########  |          |           |           |        |           |
|  Part II: |          |           |           |        |           |
|  Supporti |          |           |           |        |           |
| ng Pages- |          |           |           |        |           |
| --Work Ac |          |           |           |        |           |
| tivities  |          |           |           |        |           |
+-----------+----------+-----------+-----------+--------+-----------+
| A         |          |           | A         |        |           |
| ctivities |          |           | ctivities |        |           |
| for Year  |          |           | for Year: |        |           |
| :\_\_­\_\_ |          |           | \_\_\_    |        |           |
|           |          |           |           |        |           |
| FFY       |          |           | FFY       |        |           |
| Grant:    |          |           | Grant:    |        |           |
|           |          |           |           |        |           |
| PHA FY:   |          |           | PHA FY:   |        |           |
+-----------+----------+-----------+-----------+--------+-----------+
| **De      | **Major  | ##        | **De      | *      | **        |
| velopment | Work     | **Estimat | velopment | *Major | Estimated |
| Name      | Cate     | ed Cost** | Name      | Work   | Cost**    |
| /Number** | gories** |           | /Number** | Catego |           |
|           |          |           |           | ries** |           |
+-----------+----------+-----------+-----------+--------+-----------+
| ####      | ###      |           | #####     | #      |           |
+-----------+----------+-----------+-----------+--------+-----------+
|           | #        |           |           | ####   |           |
+-----------+----------+-----------+-----------+--------+-----------+
| ####      |          |           | ####      | ####   |           |
+-----------+----------+-----------+-----------+--------+-----------+
|           |          |           |           |        |           |
+-----------+----------+-----------+-----------+--------+-----------+
|           |          |           |           |        |           |
+-----------+----------+-----------+-----------+--------+-----------+
|           |          |           |           |        |           |
+-----------+----------+-----------+-----------+--------+-----------+
|           |          |           |           |        |           |
+-----------+----------+-----------+-----------+--------+-----------+
|           |          |           |           |        |           |
+-----------+----------+-----------+-----------+--------+-----------+
|           |          |           |           |        |           |
+-----------+----------+-----------+-----------+--------+-----------+
|           |          |           |           |        |           |
+-----------+----------+-----------+-----------+--------+-----------+
|           |          |           |           |        |           |
+-----------+----------+-----------+-----------+--------+-----------+
|           |          |           |           |        |           |
+-----------+----------+-----------+-----------+--------+-----------+
|           |          |           |           |        |           |
+-----------+----------+-----------+-----------+--------+-----------+
|           |          |           |           |        |           |
+-----------+----------+-----------+-----------+--------+-----------+
|           |          |           |           |        |           |
+-----------+----------+-----------+-----------+--------+-----------+
|           |          |           |           |        |           |
+-----------+----------+-----------+-----------+--------+-----------+
|           |          |           |           |        |           |
+-----------+----------+-----------+-----------+--------+-----------+
|           |          |           |           |        |           |
+-----------+----------+-----------+-----------+--------+-----------+
|           |          |           |           |        |           |
+-----------+----------+-----------+-----------+--------+-----------+
| #####     |          | \$        |           |        | \$        |
| # Total C |          |           |           |        |           |
| FP Estima |          |           |           |        |           |
| ted Cost  |          |           |           |        |           |
+-----------+----------+-----------+-----------+--------+-----------+