S Grant Agreement NC Tobacco Trust Fund commission and Orange Co 01-22-09-4p

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TOBACCO TRUST FUND COMMISSION Exhibit B: Grantee Quarterly & Final Report Form Quarterly Report Period: to ^ Quarterly Report ^ Flnal Report -The Final Report must ALSO include a summary of how the project goals and objectives were met, resulting benefits and future status of project. The Final Report will include a detailed financial statement on how the grant funds were spent. Date Submitted: Contact Person: (To be filed no later than fifteen days after the end of the third month of the calendar quarter) Project Title: Grantee: Address: Phone: Start date of the project: Email: County: Anticipated completion date: 1. PROJECT NARRATIVE: On a separate page or pages, write a summary of progress on your project for this report period. Provide a minimum half page narrative summary addressing the status of each of the project objectives noted in Exhibit A "Scope of Services" plus any other pertinent information. In addition to the summary, your quarterly narrative report should also address any of the following issues affecting your project during this last quarter: a) Explain any project costs that were below or above expectations. b) Explain any problems your project has encountered and steps taken to overcome them. 2. STATUS (check pertinent boxes): Project Status: ^ On Schedule ^ Completed ^ Delayed ^ Canceled Protect Cost Status: ^ Cost Unchanged ^ Cost Overrun ^ Cost Underrun 3. PROJECT IMPACT NARRATIVE: On a separate page or pages, write a summary of how grant-funded activities are affecting specific populations of people. Who are these people and how many are being served? Where do these people live? Name specific counties, towns, or neighborhoods. 4. PROJECT IMPACT TABLE: Complete all line items that pertain to your project and the activities funded by your grant. IMPACT TYPE Quarter) Im act Project to Date Jobs Created Workers Re-Em to ed Former Quota Holders Assisted Worker Skills U raded # of Workers Persons Receivin Increased Educational Trainin Amount of New Income for Former Tobacco Workers Current or Former Tobacco Farmers Assisted Acres of Farmland Protected Acres of New Cro Production Total Number of Peo le Served Dollars Levera ed State Tax Revenue Generated Other Ex lain Other Ex lain 5. EXHIBIT C: Attach your most recent Exhibit C, Financial Request Form, with the signature of the Chief Financial Officer. Authorized Signature: Project Number: Print Name: Title: