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ATTACHMENT 16•A (1)
Department of Commerce
Community Development Block Grant
CONTRACT CLOSEOUT REPORT
Contract Number: 20-62210-005
1. Grantee Jurisdiction:
2. Official Address:
Grant County
PO Box 37
Ephrata, WA 98823
3. Name of Chief Administrative Official:
4. Title:
Cindy Carter
Chair, Board of County Commissioners
5. CDBG Contract End Date or Project Completion Date:
6. Final Public Hearing Date:
6/30/2021
May 11, 2021
7. Brief project summary and results achieved: (See instructions on following page)
Subrecipient OIC provided 4 programs serving Grant & Adams Counties; Energy Assistance,
Housing/Credit/Business Counseling, Weatherization services and Farmworker services. During the
2020/21 grant period OIC had 1,612 counseling appts, 3,000 counseling hours and 10 1 St time
homebuyer classes. The Weatherization program weatherized 16 homes. Energy assistance was
provided to 2,162 households.
To reach clients, the programs were advertised in English and Spanish throughout the Grant & Adams
Counties via print and media.
❑ For construction projects, pictures of the completed project have been submitted to your CDBGJro'ect
p
Manager
8. Physical address of the activity(s) if not available at start of project (See instructions)
The chief administrative official of the grantee jurisdiction certifies that:
1. To the best of his/her knowledge and belief, the financial information and data provided in this report is true and
correct as of the signature date indicated below.
2. The project was completed in accordance with the grant contract and scope of work.
3. A final public hearing was conducted to assess project performance.
4. Records supporting the information provided in this report will be maintained for a minimum of six (6) years from
final closeout and made available upon request.
5. Consents to the use and reproduction by the CDBG Program or anyone authorized by CDBG, of any and all
provided audio or video recording or photographs without compensation.
In the event audits disclose disallowable costs, the Washington State Department of Commerce shall retain the right
to recover an appropriate amount of costs after fully considering the recommendations on disallowed costs resulting
from the final audit.
CDBG Contract Closeout Report
Signature:
Chief Administrative Official
Cindy Carter, B O C C Chair
CDBG Contract Closeout Report
ATTACHMENT 16-A (2)
4 Qvj Z6 21(
Date
ATTACHMENT 16-A (3)
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The Contract Closeout Report provides a format for grantees to certify and document project completion in
compliance with federal CDBG national objective and citizen participation requirements; and with the grant contract.
Data you provide is used to update, with actuals, what was anticipated at the beginning of the project and to
complete yearly reporting requirements.
Detailed instructions are included on the reverse side of forms that are not self-explanatory.
We recommend completing the report using the electronic version available at www.commerce.wg.gov/cdbg, or sent
by your CDBG project manager.
Please contact your CDBG project manager if you have questions
CONTRACT CLOSEOUT FACE SHEET INSTRUCTIONS
• Items 1-4 are self-explanatory.
• Item 5: Insert the end date listed on your contract face sheet or on the most recent amendment. For projects
completed prior to this end date, enter the date the project was completed.
• Item 6: Insert the date the required final public hearing was held to receive input from the public on the CDBG-
funded project. The public hearing must be held prior to submission of this report and meet public hearing
requirements.
• Item 7: Briefly describe the CDBG-funded activity(s), the original need that was met, project's actual
accomplishments compared to the CDBG contract's scope of work was accomplished, and project highlights. For
construction projects, submit digital photographs of the project by emailing, or sending a CD/flashdrive, to your
Project Manager.
• Item 8: Review the project address listed in your original application Project Summary. If it has changed, or if it
was not known at that time, provide the actual address(es) here.
• Signature Block: This is the signature of the grantee's chief administrative official or designee.
TABLE OF CONTENTS
CoverPage and Certification..................................................................................................................................... 1
Tableof Contents....................................................................................................................................................... 2
FinancialSummary..................................................................................................................................................... 3
ProgramIncome Summary........................................................................................................................................ 3
BenefitSummary....................................................................................................................................................... 5
• Benefit at Closeout Form................................................................................................................................. 7
Minority Business Development, Section 3 and Labor Standards Reporting............................................................ 9
• Contract and Subcontract Activity Form (Attachment 1) ................ ............... ........... ..... 0... ..... ....a..a..so. a..so. ... 11
• Grantee Section 3 Closeout Summary Report (Attachment 2) ............... ....... ...... ....... .............. ...............so-so. 13
• Final Labor Standards Compliance Report (Attachment 3)........................................................................... 15
CDBG Contract Closeout Report
ATTACHMENT 16-A (4)
FINANCIAL SUMMARY
PROGRAM INCOME SUMMARY
WILL THIS PROJECT GENERATE PROGRAM INCOME F-1 Yes ® No
If you check "Yes," and request to retain program income you must submit a
Program Income Reuse Plan by closeout or receipt of first loan payment
(housing rehabilitation, microenterprise assistance or other), whichever is
earlier.
Program income (PI) is defined as the gross income received by a CDBG grantee or
subrecipient that was generated from the use of CDBG funds and equals or exceeds
$35,000 in a single calendar year. For detail on program income and content of a
Program Income Reuse Plan see Section 4 CDBG Management Handbook.
L,UDU t-.urILrac;L UUSeUuL MepUr L 4
FINANCIAL SUMMARY INSTRUCTIONS:
HUD Project, Activity and Budget
Code(s): The A19 voucher lists the
Project, Activity and Budget
Codes) and Activity Title(s) for the
project.
List each Activity assigned to the
project, its corresponding Budget
Amounts, Funds Expended, and
remaining Balance(s).
Other Funding: List the other
funding sources identified in your
CDBG grant application and used
in conjunction with CDBG funds
for this project.
Sources include: State, Federal,
Local, Private, and Other. Include
the Funds Expended and remaining
Balance for each source. /,
Activities
Budget Codes Title Amount
1W nn
CDBG Contract Closeout Report 5
Project #
WASHINGTON STATE
DEPARTMENT OF COMMERCE
AGENCY NUMBER IDIS PROJECT PKIBER Commerce Gontwt Number
A,9
VOUCHER DISTRIBUTION
1030 18-62210-018
AGENCY NAME
INSTRUCTION TO VENDOR OR CLAIMANT:
DEFARTNIENT OF CO-4IIHRCE
Submit this form to claim payment for materials, merchandise orsemces.
ATT \: CDBG
Show complete detail for each item,
PO BOX 42525
OLY1"iP k I VA, 95304-2525
Vendor's Certificate: I hereby certify under perjury that the items and totals fisted herein
are proper charges for materials, merchandise or services furnished to the State of
Washington, and that all goods furnished andtorservices rendered have been provided
without discrimination because ofage, sex, marital status, race, creed, color, national
origin, handicap, religion or Vietnam era or disabled veterans status.
NTINMOR OR CLL N'T ffmreaut is to be payable to:)
SPRL"GFIELD COUNTY
100 N. ALAR\ .
DST.
By:
SHELBYVILLE, NYA 99999
(SIGN IN BLUE INK)
.-PORTING PERIOD:
(TITLE) (DATE)
Description
QUANTITY AMOUNT
PREVIOUSLY AMOUNT REMAINING
BUDGET REQUESTED THIS INVOICE BALANCE
7706
05 Public Services
35,539.00 $35,539.00
$0.00
$0.00
7707
21A Al .. al Admin
3,500.00 $3,500.00
$0.00
Budget Codes Title Amount
1W nn
CDBG Contract Closeout Report 5
8 ENEFI T S UMMA R Y
At CDBG application, the grantee identified and documented how each CDBG activity would benefit
low- and moderate -income (LMI) persons as well as the ethnic and racial breakdown. If activities
provided a benefit during the contracting period, actual beneficiary data was required during the
project. If benefit was not achieved until completion of the project, beneficiary data is reported using
the attached Beneficiary at Closeout Form.
Follow these sequential steps to document the final project benefit(s) achieved.
1. Does your CDBG contract require you currently submit a beneficiary report for your project?
(Example Public Service Grants or Local Assistance Programs)*
Yes ❑ No
• If yes, STOP, submit a new report documenting the beneficiaries since last reported and proceed
to the Minority Business Development, Section 3 & Labor Standards Section.
• If no, proceed to #2.
2. Is the project for a planning -only activity? ❑ Yes [❑ No
• If yes, STOP, data is not required, proceed to the Minority Business Development, Section 3 &
Labor Standards Section
• If no, proceed to #3
3. Complete the Benefit at Closeout Form on the next page to document the benefit provided to LMI
persons at project completion.
*NOTE: Under limited circumstances, a project may have multiple activities that require beneficiary reporting
both during the project and at completion (i.e. sewer system improvements that include replacement of private
side services). In these instances, you will receive reporting guidance from your CDBG project manager prior to
closeout.
CDBG Contract Closeout Report 6
CDBG Contract Closeout Report
BENEFIT AT CLOSEOUT FORM
Note:
• General Administration and planning budget codes do not require reporting.
• Totals for Lines 11 2, and 3 should be the same.
(Budget code and activity numbers can be found on the Contract Data Sheet sent with the executed CDBG Contract.)
Budget Code F_ 11 1 �1
Activity Number
Project Beneficiary —Persons Served
New Access (i.e. first in area)
Access to services/facility is no longer substandard
Improved access (i.e. improved proximity)
1. Total Persons
Racial/Ethnic Breakdown
*HUD has designated Hispanic as an ethnic group. A person can be identified as both a member of a racial group and an
ethnic group, but cannot be designated only as an ethnic group.
Low- and Moderate -Income Breakdown
Very Low Income (0-30% AMI)
# by
Race
# of
Hispanic*
# by
Race
# of
Hispanic
# by
Race
# of
Hispanic
White
Low to Moderate Income (51-80% AMI)
Sub -Total
Black/African American
Non-LMI (81% AMI and above)
3. Total
Asian
American Indian/Alaskan Native
Asian and White
Black /African American and White
American Indian/Alaskan Native & Black/African
American
Other Multi -Racial
2. Total
Low- and Moderate -Income Breakdown
Very Low Income (0-30% AMI)
Very Low to Low Income (31-50% AMI)
Low to Moderate Income (51-80% AMI)
Sub -Total
Non-LMI (81% AMI and above)
3. Total
CDBG Contract Closeout Report
BENEFIT AT CLOSEOUT FROM INSTRUCTIONS:
This data is reported to HUD to document how CDBG funds are used in Washington State. HUD uses
this data to report the use of CDBG funds nationally.
Budget Code and Activity Number: These are the same budget code(s) and activity numbers used on
the budget summary. If in doubt, the Contract Data Sheet sent with the executed CDBG contract lists
the budget code(s) and Activity Number(s). Complete columns for each activity assigned to the
project.
NOTE: General Administration (Budget Code 21A) and Planning (Budget Code 20) do not require
reporting.
The totals for 1, 2, and 3 should be the same number.
1. Proiect Beneficiary -- Persons Served: Choose the appropriate accomplishment and enter the total
number of beneficiaries for each activity.
2. Racial/Ethnic Breakdown: Insert the race and ethnicity for the beneficiary served at project
completion. Use the first column, labeled # by Race, to list the number of individuals by racial
group. If an individual is also of Hispanic ethnicity, count the individual also in the second column
labeled # of Hispanic.
3. Low- and Moderate -Income Breakdown: Enter the number of persons by income category. If the
30% and 50% breakdown are unknown, at a minimum, enter the total number of low -and
moderate -income beneficiaries as a "Sub -total LMI served".* The total of LMI served and non-LMI
served should be the same as sections 1, 2, and 3.
The CDBG Income Limits showing 30%, 50%, and 80% levels of area median income (AMI) by county
are available on our website at www.commerce.wa.gov/cdbunder Guidance Materials.
*Projects meeting LM - the Presumed Benefit Activities: If the activity qualified as exclusively benefiting
clientele in special groups presumed by HUD to be principally LMI persons, report the number of persons
benefiting under the following income categories unless you have information that supports reporting them
under a different income category.
Group
Income Level
Abused children
Very low income
Battered spouses
Low income
Severely disabled adults
Low income
Homeless persons
Very low income
Illiterate adults
Low income
Persons with Aids
Low income
Migrant Farm workers
Low income
Elderly
Moderate income (If to acquire, construct, convert, and/or rehabilitate senior center)
CDBG Contract Closeout Report 9
MINORITY BUSINESS DEVELOPMENT, SECTION 3 & LABOR STANDARDS REPORTING
STEP 1: Minority Business Development &Section 3:
1. If the grantee awarded professional or construction services in the past year, was it reported to
CDBG?
If no, please complete and submit, as applicable:
• Contractor and Subcontractor Activity form, if
procured since September 30 of the previous year
(Attachment 1).
• Grantee Section 3 Closeout Report, (for contracts
totaling $100,000 or more) if procured since June
30 of the previous year (Attachment 2).
Construction Projects -- proceed to Step 2.
Non -construction ProJects — the closeout report is
complete.
❑ Yes
Construction Projects -- If yes, proceed to Step 2.
Non -construction Projects — If yes, the closeout
report is complete.
STEP 2: Labor Standards (Construction projects only):
1. Has the grantee discovered federal labor standards violations not previously reported to CDBG?
❑ Yes
Using Attachment 3, report any federal labor
standards violations not previously reported.
For underpayments greater than $999.99 per
contractor, contact your CDBG project manager for
additional steps.
Complete certification below
I certify to the best of my knowledge that all laborers and
mechanics employed on this construction contract were paid in
accordance with the labor provisions. In addition, there are no
outstanding or unresolved labor standards, underpayments,
complaints, or disputes.
Signature:
Name:
Title: Date:
CDBG Contract Closeout Report 10
CDBG Contract Closeout Report 11
Revised for Internal Use with WA State CDBG Closeout 3/2016
CONTRACTAND SUBCONTRACT ACTIVITY Dept. of Housing &Urban Dev./Dept. of Commerce
Please report any business activity not previously reported (i.e. on an annual Contractor/Subcontractor Activity Form). Executive Order 12421 dated July 14, 198
shall be developed by each Federal Agency and that these annual plans shall establish minority business development objectives. The information is used by HUD to monitor and el
activity and the designated minority business enterprise (MBE) goals. The Department requires the information to provide guidance and oversight for programs for the developmei
Minority Business Development. If the information is not collected HUD would not be able to establish meaningful MBE goals nor evaluate MBE performance against these goals. V
respondents, HUD generally discloses this data only in response to a Freedom of Information request.
Privacy Act Notice - The United States Department of Housing and Urban Development, Federal Housing Administration, is authorized to solicit the information requested in this fo
1701 et seq., and regulations promulgated thereunder at Title 12, Code of Federal Regulations. It will not be disclosed or released outside the United States Department of Housing
except as required or permitted by law.
1. Grantee
2. Location (City, State, ZIP Code)
3a. Name of Contact Person
3b. Phone Number
(With Area Code)
4. Reporting Period (contract activity not previously
reported):
5. Program Code (Not applica
NA
Grant Contract #
7a.
Amount of
Contract/
Subcontract
7b
Type of
Trade
Code
(See below)
7c
Contractor or
Subcontractor
Business
Racial/Ethnic
Code
(See below)
7d.
Woman
Owned
Business
(Yes/No)
7e.
Prime
Contractor
Identification
(ID) Number
7f.
Sec.
3
(Y/N)
7g.
Subcontractor
Identification
(ID) Number
7h.
Sec.
3
(Y/N)
7i.
Contractor/Subcontrac-
7j
Name
Stree
0 = Other
7c: Type of Trade Codes:
7d: Racial/Ethnic Codes:
1= New Construction
6 = Professional
1= White Americans
2 = Substantial Rehab.
7 = Tenant Services
2 = Black Americans
3 = Repair
8 = Education/Training
3 = Native Americans
4 = Service
9 = Arch./Eng. Appraisal
5 = Project Mgmt.
0 = Other
CDBG Contract Closeout Report
HUD/Commerce "CONTRACT AND SUBCONTRACT ACTIVITY' FORM INSTRUCTIONS
Community Development Programs (CDP) -- Revised for Internal Use with State CDBG Closeout 9/2015
This report is to be completed by grantees, developers, sponsors, builders, agencies, and/or project owners for reporting contract and subcontract activities of $10,000 or more under the following
programs: Community Development Block Grants (entitlement and small cities); Urban Development Action Grants; Housing Development Grants; Multifamily Insured and Noninsured; Public and Indian
Housing Authorities; and contracts entered into by recipients of CDBG rehabilitation assistance.
Contracts/subcontracts of less than $10,000 need be reported only if such contracts represent a significant portion of your total contracting activity. Include only contracts executed during this reporting
period.
This form has been modified to capture Section 3 contract data in columns 7g and 7i. Section 3 requires that the employment and other economic opportunities generated by HUD financial assistance for
housing and community development programs shall, to the greatest extent feasible, be directed toward low- and very low-income persons, particularly those who are recipients of government assistance
for housing. Recipients using this form to report Section 3 contract data must also use Part I of form HUD- 60002 to report employment and training opportunities data. Form HUD -2516 is to be completed
for public and Indian housing and most community development programs. Form HUD -60002 is to be completed by all other HUD programs including State administered community development programs
covered under Section 3.
A Section 3 contractor/subcontractor is a business concern that provides economic opportunities to low- and very low-income residents of the metropolitan area (or nonmetropolitan county), including a
business concern that is 51 percent or more owned by low- or very low-income residents; employs a substantial number of low- or very low-income residents; or provides subcontracting or business
development opportunities to businesses owned by low- or very low-income residents. Low- and very low-income residents include participants in Youthbuild programs established under Subtitle D of Title
IV of the Cranston -Gonzalez National Affordable Housing Act.
The terms "low-income persons" and "very low-income persons" have the same meanings given the terms in section 3(b) (2) of the United States Housing Act of 1937. Low-income persons mean families
(including single persons) whose incomes do not exceed 80 per centum of the median income for the area, as determined by the Secretary, with adjustments for smaller and larger families, except that the
Secretary may establish income ceilings higher or lower than 80 per centum of the median for the area on the basis of the Secretary's findings that such variations are necessary because of prevailing levels
of construction costs or unusually high or low-income families. Very low-income persons means low-income families (including single persons) whose incomes do not exceed 50 per centum of the median
family income for the area, as determined by the Secretary with adjustments for smaller and larger families, except that the Secretary may establish income ceilings higher or lower than 50 per centum of
the median for the area on the basis of the Secretary's findings that such variations are necessary because of unusually high or low family incomes.
1. Grantee: Enter the name of the unit of government submitting this report.
3. Contact Person: Enter name and phone of person responsible for maintaining and submitting contract/subcontract data.
4. Reporting Period: For purposes of closing the CDBG grant, report new contract activity since last reported. If no new activity has occurred write or type "No New Activity" in 7a below your grant #.
7a. Grant Number: Enter the grant Contract number.
7b. Amount of Contract/Subcontract: Enter the dollar amount rounded to the nearest dollar. If subcontractor ID number is provided in 7f, the dollar figure would be for the subcontract only and not for the
prime contract.
7c. Type of Trade: Enter the numeric codes which best indicates the contractor's/subcontractor's service. If subcontractor ID number is provided in 7f., the type of trade code would be for the subcontractor
only and not for the prime contractor. The "other" category includes supply, professional services and all other activities except construction and education/training activities.
7d. Business Racial/Ethnic: Enter the numeric code which indicates the racial/ethnic/gender character of the owner(s) and controller(s) of 51% of the business.
When 51% or more is not owned and controlled by any single racial/ethnic category, enter the code which seems most appropriate. If the subcontractor ID number is provided, the code would apply to the
subcontractor and not to the prime contractor.
7e. Woman Owned Business: Enter Yes or No.
7f. Contractor Identification (ID) Number: Enter the Employer (IRS) Number of the Prime Contractor as the unique identifier for prime recipient of HUD funds. Note that the Employer (IRS) Number must be
provided for each contract/subcontract awarded.
7g. Section 3 Contractor: Enter Yes or No.
7h. Subcontractor Identification (ID) Number: Enter the Employer (IRS) Number of the subcontractor as the unique identifier for each subcontract awarded from HUD funds. When the subcontractor ID
Number is provided, the respective Prime Contractor ID Number must also be provided.
7i. Section 3 Subcontractor: Enter Yes or No.
7j. Contractor/Subcontractor Name and Address: Enter this information for each firm receiving contract/subcontract activity only one time on each report for each firm.
CDBG Contract Closeout Report 13
ATTACHMENT 2
Report any economic opportunities for low -and very low-income persons not previously reported (i.e. annual Section 3 report)
1. Grantee Name & Address: (Street, City, State, Zip)
2. CDBG Contract Number:
3. Total Amount of CDBG Award:
4. Contact Person Name:
5. Contact Person Phone:
6. Date Report Submitted:
Part 1: Employment and Training ("Columns B, C, and F are mandatory fields. Include New Hires in E & F)
A
Job Category
B
Number of New
Hires
C
Number of New
Hires that are
Sec. 3 Residents
D
% Aggregate Number of
Staff Hours of New Hires
that are Sec. 3 Residents
E
% of Total Staff Hours
for Sec. 3 Employees
and Trainees
F
Number
of Sec. 3
Trainees
Professionals
$
C.
Percentage of the total CDBG Contract dollar amount that was awarded to Section 3 businesses (B : A)
D.
Technicians
2. Non -Construction Contracts Procured:
A.
Total dollar amount of non -construction contracts awarded (CDBG funds only)
Office/Clerical
B.
Total dollar amount of non -construction contracts awarded to Section 3 businesses (CDBG funds only)
$
C.
Percentage of the total CDBG non -construction contract dollar amount awarded to Section 3 businesses
(B -!S.- A)
Construction by Trade (List)
D.
Total number of Section 3 businesses receiving CDBG non -construction contracts
Trade
Trade
Other (List)
Tota
Part II: Contracts Awarded
1.Construction Contract Procured:
A.
Total dollar of construction contracts awarded (CDBG funds only)
$
B.
Total dollar amount of contracts awarded to Section 3 businesses (CDBG funds only)
$
C.
Percentage of the total CDBG Contract dollar amount that was awarded to Section 3 businesses (B : A)
D.
Total number of Section 3 businesses receiving CDBG contracts/monies
2. Non -Construction Contracts Procured:
A.
Total dollar amount of non -construction contracts awarded (CDBG funds only)
$
B.
Total dollar amount of non -construction contracts awarded to Section 3 businesses (CDBG funds only)
$
C.
Percentage of the total CDBG non -construction contract dollar amount awarded to Section 3 businesses
(B -!S.- A)
%
D.
Total number of Section 3 businesses receiving CDBG non -construction contracts
Part III: Summary of Efforts
If no Section 3 persons were hired, or no Section 3 contracts were awarded, please provide a brief explanation as to why.
CDBG Contract Closeout Report 14
Instructions for Completing Section 3 Form:
1. Enter the name and address of the CDBG Grantee
2. CDBG Grant Contract Number
3. Enter the dollar amount of the CDBG awarded
4. Name of person completing form
5. Information for person completing form
6. Date this report submitted
Part I: Employment and Training Opportunities
➢ Column A: Contains various job categories. Professionals are defined as people who have special knowledge of an occupation
such as architects, grant administrators, engineers, etc. For construction positions, list each trade and provide data in columns B
through F for each trade where persons were employed. The category of "Other" includes occupations such as service workers.
➢ Column B: (MANDATORY FIELD) Enter the number of New Hires for each category of workers identified in Column A in
connection with this contract award. "New Hires" refers to a person who is not on either the recipient's or the contractor's
payroll at the time the contract was awarded.
➢ Column C: (MANDATORY FIELD) Enter the number of Section 3 new hires for each category of workers identified in Column A in
connection with this contract award. "Section 3 New Hires" refers to a Section 3 resident who is not on either the recipient's or
the contractor's payroll at the time the contract was awarded.
➢ Column D: Enter the percentage of Section 3 New Hire staff hours spent on this contract. (Section 3 New Hire Hours : Total New
Hire Hours)
➢ Column E: Enter the percentage of the total staff hours worked by Section 3 employees and trainees on this contract — including
new hires. Also include staff hours for full time and part time employees. (Section 3 Employee Hours : Total Employee Hours)
➢ Column F: (MANDATORY FIELD) Enter the number of Section 3 residents that were trained in connection with this contract.
Part II: Contract Opportunities
Block I: Construction Contracts
Item A: Enter the total dollars amount of CONSTRUCTION contracts awarded on the contract (CDBG dollars only).
Item B: Enter the dollar amount of Section 3 contracts awarded on the contract (CDBG dollars only).
Item C: Enter the percentage of Section 3 contracts awarded on the contract (CDBG dollars only). Section 3 contract dollars
Total contract dollars.
Item D: Enter the number of Section 3 businesses receiving contract awards in association with this contract.
Block II: Non -Construction Contracts
Item A: Enter the total dollar amount of NON CONSTRUCTION contracts awarded on the contract (CDBG dollars only).
Item B: Enter the dollar amount of Section 3 contracts awarded on the contract (CDBG dollars only).
Item C: Enter the percentage of Section 3 contracts awarded on the contract (CDBG dollars only). Section 3 dollars : Total
contract dollars.
Item D: Enter the number of Section 3 businesses receiving contract awards in association with this contract.
Part III: Summary of Efforts — Self Explanatory
CDBG Contract Closeout Report 15
ATTACHMENT 3
LABOR STANDARDS COMPLIANCE REPORT
This Form Must Be Used for Restitution (Underpayments) of $.00 to $999.99. (See Federal Labor Standards Handbook
1344.1, for amounts totaling 1000 or more per prime or subcontractor)
PROJECT INFORMATION
CDBG Contract #: HUD Program or Source of Funds: WA State CDBG
Grantee Name and Address:
Description of Work:
Prime Contractor:
Contract Amount: $
VIOLATIONS
Number of Violations:
Number of Employees Involved in Violations:
Number of Subs Involved -Violations:
Total Amount of Straight Time Underpayments (restitution): $
Total Amount of Overtime Underpayments (restitution): $
(Federal Contract Work Hours &Safety Standards Act violations only)
Briefly Describe Any Labor Standards Complaints &Resolutions:
------------
Is any contractor retainage held at this time? F-1 Yes ❑ No Amount of retainage held: $
SUBCONTRACTOR(S) WHO HAD VIOLATIONS:
(Please attach more pages, if needed, for any additional information)
Name Address Contract Type of Work
Amount
---------------
---------------------------------
CERTIFICATION
I CERTIFY TO THE BEST OF MY KNOWLEDGE THAT ALL LABORERS AND MECHANICS EMPLOYED ON THIS CONSTRUCTION CONTRACT
WERE PAID IN ACCORDANCE WITH THE LABOR PROVISIONS, EXCEPT AS NOTED. THERE ARE NO OUTSTANDING OR UNRESOLVED
LABOR STANDARDS, UNDERPAYMENTS, COMPLAINTS, OR DISPUTES.
Signature:
Name:
Title:
Date:
CDBG Contract Closeout Report 16