ࡱ> C +bjbj\\ >h>h#$ $ Dzlh)(((((((($+. )!!! )")'''!R('!('''!#E"'(8)0h)'f/"f/'f/'v T's D < ) )&h)!!!!f/$ X |: New Jersey Historic Preservation Fund CAPITAL PRESERVATION GRANT FINAL REPORT & RETAINAGE FORM Project Project Name: Organization: Project Contact: Phone: Email: Date: Check List The following Items are to be included in the final report. The report must be sent hard copy to the Trust with original signatures. Final Report: ___ Attachment C-2, pgs. C-2.1 C-2.3 completed and signed _ Current Status and Phase update (item 1) _ Final Project Team List (item 2) _ Narrative Description (item 3) _ Final Photographs (item 4) Before and after photographs Photograph of permanent plaque Letter from project architect certifying project is complete _ Other Materials (item 5: specify):  Final employment figures ____ Total project cost As-built drawings _ Signature Certification on page C-2.3 ____ Financial audit (if applicable) ____ State / National Register Listed Reimbursement: ___ Attachment C-2, pgs. C.4 C.5 completed and signed Copies of Invoices attached to corresponding cancelled checks not presented in previous reports ___ Reimbursement Tabulation Chart (C-1.6) ___ State of New Jersey Payment Voucher (with original signature of CFO or Treasurer) Other attachments (specify): 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): bidding code review construction project closeout completed 2. FINAL PROJECT TEAM LIST Please list the Business Name, Mailing Address, Phone Number, Email Address, and Personnel, along with their title or role, for each consultant involved in the project. 3. SUMMARY OF PROJECT On a separate sheet, please describe the funded project, from beginning to completion. Reference the Scope of Work, Attachment D1. Please be thorough but concise, particularly noting changes to the project from originally anticipated. All changes in the Scope of Work must receive prior approval from the New Jersey 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 Attachment D-2.3 for the Application for Major Change form. Explain deviations. 4. FINAL PHOTOGRAPHS Photos of completed project: Attach photographs (3 by 5" prints or larger) in photo sleeves or digital photographs on CD with color-printed images on photo quality paper. Please label the photographs with the project name, date, and a brief description of the work depicted. Provide images of resource before project began and at completion. Include photographs of craftspeople and contractor staff at work. Photo of Permanent plaque: Grantees are required to post a permanent sign or plaque on the building before completion of the project. The sign must be approved in advance by the Trust and include the following information: date of structure, name, and a brief description of historical significance. The plaque must credit the Trust grant, and read as follows: Funding has been made possible in part by the Preserve New Jersey Historic Preservation Fund administered by the New Jersey Historic Trust, State of New Jersey. 5. OTHER MATERIALS Final Employment Figures: These should be obtained from BOTH the Architect and Contractor, stating the number of professional personnel and the number of trade personnel employed on the project (combined, full and part-time). Please enter the required information below: No. of Professional Personnel Employed No. of Non-Professional (Trade/Construction) Personnel Employed As-Built Drawings: Provide a final, revised set of drawings for the funded project, reflecting the project as completed. Other: Please attach any other significant activity of your organization since the last report, 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. 6. CERTIFICATION We certify this report to be true and correct. Submitted this day of , 201 . Signature of person completing report Name (printed) New Jersey Historic Preservation Fund CAPITAL PRESERVATION GRANT FINAL REPORT & RETAINAGE FORM Project Number: Project Name: Organization: Final 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 this PeriodCumulative Amount of Previous CostsBalance Of Project RemainingA. Non-Construction   B. Construction   E. Total $$ $ $  Please explain any substantial changes or deviations to Budget here: New Jersey Historic Preservation Fund CAPITAL PRESERVATION GRANT FINAL REPORT & RETAINAGE FORM Project Number: Project Name: Organization: Additional Payments since last Report: Attach photocopies of any additional grant-related costs incurred. Provide the invoice and corresponding cancelled checks, stapled together, in the order that they appear below. Append continuation pages as necessary                         Total Cost: (Allowable Expenses this period)$$  A. Total Grant Amount $ B. Amount Now Requested $ (5% of Grant Amount) C. Amount Previously Requested $ D. Balance of Grant Remitted [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 New Jersey Historic Trust.  MERGEFIELD CFO  Date Name and Title of Chief Financial Officer Signature  NJ Department of Community Affairs Transmittal and Payment Voucher  Date: ____________ To: New Jersey Historic Trust, Room 604, PO Box 457  Payee Reference: Project #: __________________ Project Name: __________________ Reimbursement # ______ Grantee: __________________ Grant Agreement Begins: ______Ends: ______  Payment Reporting Period_____________ to ____________ Close-Out / Retainage 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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