American Reinvestment and Recovery Act (ARRA)
Sub-Recipient Information Sheet

Please select the applicable reporting period and note the due date for this report. Select Reporting Period / Due Date for Report January - March 2011 / Due April 1, 2011 April - June 2011 / Due July 1, 2011 July - September 2011 / Due October 3, 2011 October - December 2011 / Due January 4, 2011 January - March 2012 / Due April 1, 2012 April - June 2012 / Due July 1, 2012 July - September 2012 / Due October 1, 2012 October - December 2012 / Due January 4, 2013

Please provide the following information:

Agency Information

Agency Name:

Subaward/Grant Number:

Street Address:

City:

State:   Zip Code+4:   Telephone:

DUNS Number:

Congressional districts served by this grant:

This Grants Main Office serves the Congressional District.

Please provide other counties, Congressional Districts and Zip Codes (+4) serviced by this grant.

Select County 1 Alamance Alexander Allegheny Anson Ashe Avery Beaufort Bertie Bladen Brunswick Buncombe Burke Cabarrus Caldwell Camden Carteret Caswell Catawba Chatham Cherokee Chowan Clay Cleveland Columbus Craven Cumberland Currituck Dare Davidson Davie Duplin Durham Edgecombe Forsyth Franklin Gaston Gates Graham Granville Greene Guilford Halifax Harnett Haywood Henderson Hertford Hoke Hyde Iredell Jackson Johnston Jones Lee Lenoir Lincoln Macon Madison Martin McDowell Mecklenburg Mitchell Montgomery Moore Nash New Hanover Northampton Onslow Orange Pamlico Pasquotank Pender Perquimans Person Pitt Polk Randolph Richmond Robeson Rockingham Rowan Rutherford Sampson Scotland Stanly Stokes Surry Swain Transylvania Tyrrell Union Vance Wake Warren Washington Watauga Wayne Wilkes Wilson Yadkin Yancey   Congressional District    Zip Code +4
Select County 2 Alamance Alexander Allegheny Anson Ashe Avery Beaufort Bertie Bladen Brunswick Buncombe Burke Cabarrus Caldwell Camden Carteret Caswell Catawba Chatham Cherokee Chowan Clay Cleveland Columbus Craven Cumberland Currituck Dare Davidson Davie Duplin Durham Edgecombe Forsyth Franklin Gaston Gates Graham Granville Greene Guilford Halifax Harnett Haywood Henderson Hertford Hoke Hyde Iredell Jackson Johnston Jones Lee Lenoir Lincoln Macon Madison Martin McDowell Mecklenburg Mitchell Montgomery Moore Nash New Hanover Northampton Onslow Orange Pamlico Pasquotank Pender Perquimans Person Pitt Polk Randolph Richmond Robeson Rockingham Rowan Rutherford Sampson Scotland Stanly Stokes Surry Swain Transylvania Tyrrell Union Vance Wake Warren Washington Watauga Wayne Wilkes Wilson Yadkin Yancey   Congressional District    Zip Code +4
Select County 3 Alamance Alexander Allegheny Anson Ashe Avery Beaufort Bertie Bladen Brunswick Buncombe Burke Cabarrus Caldwell Camden Carteret Caswell Catawba Chatham Cherokee Chowan Clay Cleveland Columbus Craven Cumberland Currituck Dare Davidson Davie Duplin Durham Edgecombe Forsyth Franklin Gaston Gates Graham Granville Greene Guilford Halifax Harnett Haywood Henderson Hertford Hoke Hyde Iredell Jackson Johnston Jones Lee Lenoir Lincoln Macon Madison Martin McDowell Mecklenburg Mitchell Montgomery Moore Nash New Hanover Northampton Onslow Orange Pamlico Pasquotank Pender Perquimans Person Pitt Polk Randolph Richmond Robeson Rockingham Rowan Rutherford Sampson Scotland Stanly Stokes Surry Swain Transylvania Tyrrell Union Vance Wake Warren Washington Watauga Wayne Wilkes Wilson Yadkin Yancey   Congressional District    Zip Code +4
Select County 4 Alamance Alexander Allegheny Anson Ashe Avery Beaufort Bertie Bladen Brunswick Buncombe Burke Cabarrus Caldwell Camden Carteret Caswell Catawba Chatham Cherokee Chowan Clay Cleveland Columbus Craven Cumberland Currituck Dare Davidson Davie Duplin Durham Edgecombe Forsyth Franklin Gaston Gates Graham Granville Greene Guilford Halifax Harnett Haywood Henderson Hertford Hoke Hyde Iredell Jackson Johnston Jones Lee Lenoir Lincoln Macon Madison Martin McDowell Mecklenburg Mitchell Montgomery Moore Nash New Hanover Northampton Onslow Orange Pamlico Pasquotank Pender Perquimans Person Pitt Polk Randolph Richmond Robeson Rockingham Rowan Rutherford Sampson Scotland Stanly Stokes Surry Swain Transylvania Tyrrell Union Vance Wake Warren Washington Watauga Wayne Wilkes Wilson Yadkin Yancey   Congressional District    Zip Code +4
Select County 5 Alamance Alexander Allegheny Anson Ashe Avery Beaufort Bertie Bladen Brunswick Buncombe Burke Cabarrus Caldwell Camden Carteret Caswell Catawba Chatham Cherokee Chowan Clay Cleveland Columbus Craven Cumberland Currituck Dare Davidson Davie Duplin Durham Edgecombe Forsyth Franklin Gaston Gates Graham Granville Greene Guilford Halifax Harnett Haywood Henderson Hertford Hoke Hyde Iredell Jackson Johnston Jones Lee Lenoir Lincoln Macon Madison Martin McDowell Mecklenburg Mitchell Montgomery Moore Nash New Hanover Northampton Onslow Orange Pamlico Pasquotank Pender Perquimans Person Pitt Polk Randolph Richmond Robeson Rockingham Rowan Rutherford Sampson Scotland Stanly Stokes Surry Swain Transylvania Tyrrell Union Vance Wake Warren Washington Watauga Wayne Wilkes Wilson Yadkin Yancey   Congressional District    Zip Code +4
Select County 6 Alamance Alexander Allegheny Anson Ashe Avery Beaufort Bertie Bladen Brunswick Buncombe Burke Cabarrus Caldwell Camden Carteret Caswell Catawba Chatham Cherokee Chowan Clay Cleveland Columbus Craven Cumberland Currituck Dare Davidson Davie Duplin Durham Edgecombe Forsyth Franklin Gaston Gates Graham Granville Greene Guilford Halifax Harnett Haywood Henderson Hertford Hoke Hyde Iredell Jackson Johnston Jones Lee Lenoir Lincoln Macon Madison Martin McDowell Mecklenburg Mitchell Montgomery Moore Nash New Hanover Northampton Onslow Orange Pamlico Pasquotank Pender Perquimans Person Pitt Polk Randolph Richmond Robeson Rockingham Rowan Rutherford Sampson Scotland Stanly Stokes Surry Swain Transylvania Tyrrell Union Vance Wake Warren Washington Watauga Wayne Wilkes Wilson Yadkin Yancey   Congressional District    Zip Code +4
Select County 7 Alamance Alexander Allegheny Anson Ashe Avery Beaufort Bertie Bladen Brunswick Buncombe Burke Cabarrus Caldwell Camden Carteret Caswell Catawba Chatham Cherokee Chowan Clay Cleveland Columbus Craven Cumberland Currituck Dare Davidson Davie Duplin Durham Edgecombe Forsyth Franklin Gaston Gates Graham Granville Greene Guilford Halifax Harnett Haywood Henderson Hertford Hoke Hyde Iredell Jackson Johnston Jones Lee Lenoir Lincoln Macon Madison Martin McDowell Mecklenburg Mitchell Montgomery Moore Nash New Hanover Northampton Onslow Orange Pamlico Pasquotank Pender Perquimans Person Pitt Polk Randolph Richmond Robeson Rockingham Rowan Rutherford Sampson Scotland Stanly Stokes Surry Swain Transylvania Tyrrell Union Vance Wake Warren Washington Watauga Wayne Wilkes Wilson Yadkin Yancey   Congressional District    Zip Code +4

Jobs Data (for current reporting period only)

Jobs should be reported as Full Time Equivalents (FTE). An FTE is calculated as the total hours worked in jobs created or retained divided by the number of hours in a full time schedule. If full time employment at your agency equals 520 hours for the quarterly reporting period, then one FTE equals 520 hours for the quarterly reporting period. (40 hrs. multiplied by 52 wks. = 2,080 hrs. in a work year, divided by 4 quarters = 520)

Example: October 1 thru December 31 Quarterly Report

Position Title	Days Worked (A)	Hours per Day (B)	Subtotal (AxB)	FTE
Victim Counselor	65	8	520
Part-time Therapist	65	4	260
Quarterly Total	130	12	780	1.5

**In this example, the Total for the subtotal column is 780 hours worked by the two employees. This is divided by the total of 520 potential work hours in a quarter per employee and equals 1.5 Full Time Equivalents. (780/520 = 1.5)

Please report on the jobs(s) created or retained below: (This information should reflect the information reported on time sheets applicable to this reporting period.)

Jobs Retained

Vendor Information: Agencies must report jobs created or retained by vendors (Contractual Services).

Did this project support Contractual services during this reporting period? Yes    No

If "Yes" please provide the following information.

Vendor DUNS number

Vendor Name

Vendor's main office address

City: State:   Zip Code+4: