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PEPSA Grant Report
Year-end report due February 10, 2020
For the Program Activity Grant Funded by PEPSA
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Indicates required field
Date Submitted
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Agency Name
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Program Name
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Agency or Corporate CEO Name
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First
Last
Agency or Corporate CEO Address
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Line 1
Line 2
City
State
Zip Code
Country
Agency or Corporate CEO Phone
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Agency or Corporate CEO Email
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Federal Identification Number
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Project Coordinator
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Fiscal Officer
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First
Last
Name of Person Submitting Grant Report
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First
Last
Submitter's Title
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Submitter's Email
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Certification
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To the best of my knowledge, all of the statements in this report are true and correct.
Budget
Please use your PEPSA Grant you submitted for reference.
Enter whole numbers only. Do not enter cents, dollar signs, commas or text.
PEPSA Original Grant Amount
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Amount Expended
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Balance Remaining (Read Only) Calculated from above entries.
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Below please report expenses YTD which pertain to the PEPSA monies. Do not include your total program budget with other revenue sources. We only wish to understand how you have spent down the PEPSA monies. These figures should match your approved allocation and/or grant proposal.
YTD Expenses:
Salaries
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Personnel Benefits
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Facilities
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Travel
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Office Supplies
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Equipment
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Administrative
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Other (as outlined and approved in your grant)
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Total Expenses (Read Only) Calculated from above entries.
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Attendance
A representative of my (grantee) program attended Partnership meetings/activities on the following dates:
Representative Name(s)
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First
Last
Number of Membership Meetings Attended
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Number of Committee Meetings Attended
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This person is a member of the following committee(s)
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Criminal Justice
Prevention
Treatment
Executive
Program Progress
On your grant proposal you outlined how you would address one of the Partnership’s recommended actions. In the space below outline specifically how your funded program has made an impact on the “recommended action” you picked.
Include relevant statistics which relate to the recommended action you chose. It is essential that you are detailed on how successful you have been in making an impact on your selected recommended action and as a result helping to reach the outlined goal. Make sure the recommended action matches the one you selected in your original grant proposal.
Include the number of individuals served by your program.
Limit 1000 characters (Approx. 150 words) / characters remaining
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Section A: All funded programs. Any organization receiving PEPSA monies must address a recommended action from the approved Comprehensive Plan. The following section pertains to your work within these action items. This section of the report must be complete and detailed.
In your approved grant, you stated you would focus on one of recommended actions.
Refer to your grant application and list below:
Limit 1000 characters (Approx. 150 words) / characters remaining
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Other
Please use this section to provide any other information you deem important or relevant. Please feel free to include short success stores (150 word max), further explanations pertaining to program changes or reasons the program has been altered from the one proposal.
Limit 1000 characters (Approx. 150 words) / characters remaining
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Any Additional Information
Limit 1000 characters (Approx. 150 words) / characters remaining
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Please attach the following:
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Max file size: 20MB
Attachments should be uploaded as one attachment. Maximum file size 20Mb. PDF file format only.
A blank copy of any pre/post -test used including participant surveys used in your program (only required once)
Copies of press releases, newspaper articles, etc. that acknowledge PEPSA funding.
Copies of workshops/conference brochures if we funded training (cover is sufficient) that acknowledge PEPSA funding.
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