ࡱ> C 1bjbj\\ 9>h>h($ $ dl6L&7&9&9&9&9&9&9&$@)+]& ]| ]&r&;%;%;% R7&;% 7&;%;%;%1O#[ v;%#&&0&;%, ,;%,;%>,;%C$g]&]&Y$& ,$ X |: ԹϺ Historic Preservation Fund CAPITAL PRESERVATION GRANT QUARTERLY PERFORMANCE REPORT & REIMBURSEMENT FORM Project Number: Project Name: Organization: Project Contact: Phone: Email: Report Due Date: Reporting Period: from to Check List Provide performance report items listed below. If reimbursement payment on grant is requested, also provide the reimbursement checklist items below. If there is no reimbursement request, the report can be e-mailed or sent hard copy. If there is a reimbursement, the report must be sent hard copy with original signatures and copies of the items below. Quarterly Performance Report: ___ Attachment C-1, pgs. C-1.1 C-1.3 _ Current Status and Phase update (item 1) _ Project Team List (item 2) _ Narrative Description (item 3) _ Current schedule (item 4) _ Photographs (item 5) _ Other Materials (item 6: specify): drawings project meeting minutes list/schedule of change orders (if applicable) Other: _ Signature Certification, page C-1.3 (Item 7) Reimbursement: ___ Completed performance Report (as above) ___ Attachment C-1, pgs. C-1.4 C-1.5 Copies of Invoices attached to corresponding cancelled checks ___ Statement of Expenditures Spreadsheet ___ State of ԹϺ Payment Voucher (with original signature of CFO or Treasurer) Other attachments (specify): Reporting Schedule: Performance Reports are due quarterly Reporting PeriodsQuarterly Due DateJan. 1 March 31April 15April 1 June 30July 15July 1 Sept. 30Oct. 15Oct. 1 Dec. 31Jan 15 1. CURRENT STATUS AND PHASE Identify the current phase of work and circle the current status of the project. Phase of Work (if applicable): ___________________ Status (Please Circle): predesign schematic design design development contract documents bidding code review construction project closeout completed 2. PROJECT TEAM LIST First Performance Report: On a separate sheet, please list the Business Name, Mailing Address, Phone Number, Email Address, and Personnel, along with their title or role, for each consultant, contractor and sub-contractor involved in the project. Subsequent Performance Report: Did your project team remain the same since the last report? yes no If no, please explain any changes and list the above information for each. 3. NARRATIVE DESCRIPTION On a separate sheet, please describe all work (a) currently in progress and (b) completed in this reporting period. Reference the Scope of Work, Attachment D1. Please be thorough but concise. All changes in the Scope of Work must receive prior approval from the ԹϺ Historic Trust. Major changes will need an Application for Major Change completed by the grantee and signed off on by the Trust. Refer to Section XII, Project Revision and Modification, in the Grant Agreement for definition of major change and completed Attachment D-2.3/Application for Major Change. Explain the deviations. 4. CURRENT PROJECT AND CONSTRUCTION SCHEDULE On a separate sheet please provide an uptodate project schedule. Include estimated installation and completion dates for major work items being funded, dates when samples and mockups of funded items are to be reviewed for approval, time and location of upcoming job site meetings, and estimated project completion date. Establish and confirm this information from your professional consultant and/or contractor. Maintain a format consistent with the complete project specified in Attachment D1. All delays to the scope of work and work schedule specified in Attachment D1 to the Grant Agreement must receive prior approval from the ԹϺ Historic Trust. Major changes (changes of more than 90 days) will need an Application for Major Change completed by the grantee and signed off on by the Trust. Refer to Section XII, Project Revision and Modification, in the Grant Agreement for definition of major change and Attachment D-2.3 for the Application for Major Change form. Explain all schedule deviations. 5. PHOTOGRAPHS Attach photographs (3 by 5" prints or larger) of funded work in progress. Please label all photographs with the project name, number, the date, and a brief description of the work depicted. Submit the photos in plastic sleeves. If submitting digital photos, include color prints on quality paper, plus images on a CD. 6. OTHER MATERIALS Please attach any other significant activity of your organization such as drawings, project meeting minutes, research, project management, work schedules, marketing, or programming that is relevant to the funded work. Also, note any innovative or unusual techniques or materials used in the project work. 7. CERTIFICATION I certify this report to be true and correct. Submitted this day of , 201 . Signature of person completing report Name (printed) ԹϺ Historic Preservation Fund CAPITAL PRESERVATION GRANT REQUEST FOR REIMBURSEMENT Project Number: Project Name: Organization: Reporting Period: from: to: Current Project Budget Total approved budget for each category should correspond with the categories on Attachment B of the Grant Agreement. Categories of WorkTotal Approved BudgetCosts in this PeriodCumulative Amount of Previous CostsBalance Of Project RemainingA. Non-Construction   B. Construction   E. Total $$ $ $  Please explain any changes or deviations to Budget here: ԹϺ Historic Preservation Fund CAPITAL PRESERVATION GRANT REQUEST FOR REIMBURSEMENT Project Number: Project Name: Organization: Reporting Period: from: to: Attach photocopies of each invoice and corresponding cancelled checks, stapled together, and in the order that they appear below. Append continuation pages as necessary. (Note: A 5 % retainage must be deducted from reimbursement. Calculate as instructed under line B. below.) Payee Invoice Check # Cost(NJHT use only) Approved Cost                                        Total Cost: (Allowable Expenses this period)$$  A. Total Grant Amount $ B. Amount Now Requested $ (Total Cost in period x .57) C. Amount Previously Requested $ D. Balance of Grant Remaining [A(B+C)] $ I certify that the above disbursements for which reimbursement is requested have been made in accordance with the standards and conditions contained in the Grant Agreement with the ԹϺ Historic Trust.  MERGEFIELD CFO  Date Name and Title of Chief Financial Officer Signature NJ Department of Community Affairs Transmittal and Payment Voucher  Date: ____________ To: ԹϺ Historic Trust, Room 604, PO Box 457  Payee Reference: Project #: __________________ Project Name: __________________ Reimbursement # ______ Grantee: __________________ Grant Agreement Begins: ______Ends: ______ Payment Reporting Period ______________ to _________________ Reimbursement Amount $__________________   Grantee Certification: I certify that the within Fiscal Monitoring Report Payment Voucher is correct in all its particulars and the described goods or services have been furnished or rendered and that no bonus has been given or received on account of said document. ___________________ ___________________ __________________ Typed Name of CFO/Treasurer Original Signature Date use BLUE or Red ink only NJHT Certification: I certify that the articles have been received or services rendered as stated herein. 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