State of Wisconsin
CDBG Housing Revolving Loan Fund Activity Report

Complete the following for housing-related revolving loan fund income received during the period (04/01/16 to 03/31/17). Sign and return this form to the Division of Energy Housing and Community Resources (DEHCR) by 04/24/2017.

NOTE: All fields are required except for the Miscellaneous Activities field.

Section 1
Please provide the name, address, phone number and email of the clerk

Phone Number:   - -
- -

Section 1B
Please provide name, address, phone number and e-mail of the Revolving Loan Fund Administrator

Phone Number:  ( - - )
- -

Section 2

When entering any dollar amount, you do not need to add the "$". Just enter the amount. Example: 34502.34


(This includes all repaid housing loans and interest earned):

(The total payments for all loans and grants made from the housing revolving loan funds during the reporting period):

(The total amount of housing revolving loan funds used for administrative costs during the reporting period):
Summary of housing activity during reporting period:



(List any other eligible CDBG activities that utilized revolving loan funds other than rehabilitation or administration such as acquisition and relocation):

Section 3
(Include any CDBG housing funds returned during reporting period):

at the end of this reporting period (Submit copy of housing RLF bank statement(s) for month ending 3/31/17 and the CDBG Housing RLF Accounting Journal):

Verification Text:
Enter the red text below into the adjacent form field then press "Submit".