Spreadsheet: 42e53d86-5179-42b5-9490-0c31faaf2cef
Sheet: CoverSheet

 |  | Click Here to complete your agency's Final IS Report
 |  | State of Colorado Department of Local Affairs Community Services Block Grant         Quarterly Performance Report
 |  | Agency Name:
 |  | Title and Name of Person Completing this Report:
 |  | Phone:
 |  | email:
 |  | Reporting Period: (Check which reporting period this report is applicable to)
 |  | December 1 through February 28
 |  | March 1 through May 31
 |  | June 1 through August 31
 |  | September 1 through November 30
 |  | Final "IS" Report (March 31)
 |  | Federal Objective: (complete one report for each federal objective carried-out)
 |  | Employment
 |  | Education
 |  | Income Management
 |  | Housing
 |  | Emergency Services
 |  | Nutrition
 |  | Linkages
 |  | Self Sufficiency
 |  | Health
 |  | 1. How many participants were served during this reporting period:
 |  |  |  | Yes | No
 |  | 2. Is this number on track with the “projected” number of clients from your application and plan?
 |  | 3. On what date/s did your tri-partite board meet during this reporting period? (Include a copy of all meeting minutes that occurred during the reporting quarter in your email.)
 |  | 4. Were there updates or changes to the Tripartite Board during this reporting period, if so please explain:
 |  | 5. For “Linkages” programs, provide specific activities undertaken, the purpose of the activity and the outcome for the client or community. Describe what kinds of new collaborative partnerships were formed (or strengthened) between your agency and other organizations as a result of the activity. Simply providing a list of meetings attended is not sufficient.
 |  | 6. Please identify any problems encountered during the reporting period, and include what actions your organization has taken or plans to take to resolve the issue:
 |  | 7. If you need training or technical assistance from DOLA, you may request it here. Please be specific.
 |  | I hereby certify to the best of my knowledge and belief that the information in this report, including any supplemental information, is true and correct.
 |  | Signature of Responsible Administrator |  |  | Date
 |  | Print Name of Responsible Administrator |  |  | Date
 |  | Stop - Next Section is for your Agency's Final IS Report - Stop
 |  | CSBG FINAL IS PROGRAM REPORT DUE MARCH 31 EACH YEAR MUST BE COMPLETED AND ACCOMPANIED WITH: NATIONAL INDICATORS FORMS, SECTIONS D. E. F. AND G.
 |  | Agency Name:
 |  | Period Ending
 |  | NATIONAL INDICATORS:
 |  |  | This must match with the one identified in the application and plan.
 |  | Program:
 |  | Actual Amount of the CSBG spent: $
 |  | Name & Title of Person Filling this Report:
 |  | Address:
 |  | Phone Number:
 |  | Program Director Signature (please type your name authorizing submission of this report):
 |  | Program Director[NAME] and Title:
 |  | Please remember that the answers to these questions must relate to your original application and current grant contract.
 |  | 7. What services/assistance did you provide your clients? List all that apply (separate services by commas). For example:  mortgage/rent assistance, homeownership counseling services, food boxes, job readiness, etc.
 |  | 8. What was the outcome for the client as a result of the service? (separate outcomes by commas). For example: unemployed & obtained a job, removed barriers to education, maintained an independent living situation, etc.
 |  | 9. How many Persons are more self-sufficient as a result of your services?
 |  | 10. How many Persons moved out of poverty as a result of your services (126% of FPL)?
 |  | 11. Provide one example of the impact of services provided. Give an overall picture, the struggles/accomplishments, partnerships, other resources utilized and how this made an impact to the intended recipient(s). Use additional paper if needed.
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