Evaluation for Quarter Ending:   (1) ________, 19__

1. a. Name of Grantee:   (2) ___

b. Address:   (3) ___

c. Area the grant serves:   (4) ___

2. Date of Agreement:   (5) ___ Time Extended   (6) ___

3. a. Equivalent unit increase during quarter:

First Month

Second Month

Third Month

b. Cumulative total number of Equivalent Units since beginning of grant:

Total to Date

4. a. Method of Construction:

Stick built ___%, Panelized ___%, Combined ___%

b. Number of bedrooms per house built this grant period:

c. Household size this Quarter:

1 person ___,

2 persons ___,

3 persons ___,

4 persons ___,

5 persons ___.

d. Number of houses under construction this grant period, but started during previous grant period: ___

5. a. Number of houses proposed under this grant:

b. Number of houses completed under this grant:

c. Number of houses currently under construction:

d. Number of families in pre construction:

e. Number of Construction Supervisors:

f. Number of TA employees:

6. a. Average time needed to construct a single house:

b. Number of months between submission of self-help borrower's docket and approval/rejection:

c. Number and percentage of loan docket rejections during reporting period: ___

7. a. Did any of the following adversely affect the Grantee's ability to accomplish program objectives?

8. Attach information concerning number of families contacted, number who have indicated a willingness to be a participating family, number of mutual self-help groups organized, progress on any construction started, and any problems relating to the operation of this grant.

I certify that the statements made above are true to the best of my knowledge and belief.

(Date)

(Title)

GRANTEE

(Signature)

County Office Review

I have reviewed the above information which I have found to be substantially correct. Must be completed by County Office.

Comment: Must be completed   (23)

Average appraisal value of units financed this Quarter:

Average amount loan per unit financed this Quarter:

(Date)

County Supervisor

District Office Review

Comment: Must be completed   (26)

Date

District Director

State Office Review

Comments: Must be completed   (29)

Date

State Office Representative