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INSTRUCTIONS: <br />No Voucher will be paid unless your quarterly reports are up to date. All sections must total the number of persons <br />assisted. This form should be completed by the contract subrecipient and sent to the CDBG Grantee (county). The CDBG <br />Grantee (county) should send this form to the CDBG project manager. <br />This form has been updated to calculate totals in each column. To activate the imbedded Excel table in the worksheet; you <br />must double click on the table area, to close the worksheet just click outside the table area. <br />Item 1: Unduplicated Count of Persons Assisted. <br />Reporting Period: <br />Insert the unduplicated number of clients served during the reporting period. Unduplicated means that one person served by your <br />agency is counted once during the calendar year. You may report only those persons for whom you maintain written records. This <br />record must be established at the time the person is first served by your agency. <br />Race: <br />Insert the ethnicity for the unduplicated clients served during this reporting period. When completing this section, if the individual <br />is not Hispanic or Latino, use the first column labeled #Total. If the individual is Hispanic, use the first column to identify race <br />(which gives us a total), then count the individual in the second column, which is a subset of the first column. <br />Single Head of Household; Elderly, and Disabled: <br />Insert the unduplicated number of single female head of households with dependents/children served during the reporting period. <br />Insert the unduplicated number of Elderly and Disabled, if your agency tracks this data. If services are provided to "Elderly" <br />populations with CDBG funds, it is expected that your agency will track this data <br />Income: <br />Insert the unduplicated clients (not households) served who are Moderate Income (51-80%), Low -Income (31-50%) and <br />Extremely Low -Income (0-30%) <br />70 <br />