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C, 31. For each of the following wage categories, indicate the number of actual jobs created and/or retained since the benefit date and the actual hourly value of any employer-provided health insurance for those jobs. (Only indicate job creation in full-rime equivalents if you are unable to separate job creation into full- and part-time positions.) Full-time Part-time! FTE onl if unable to Hourly Wage Job Seasonal/I'emp. stated as FT/PT) Hourly Valve of (excluding benefits) Creation Job Creation Job Creation .Job Retention Health Insurance less than $7.00 $ $7.00 to $8.99 $ $9.00 to $10.99 $ $11.00 to $12.99 $ $13.00 to $14.99 $ $15.00 and higher $ 32. Has the recipient achieved all goals (see Question 33, 34 and 35) and fulfilled all obligations stipulated in the agreement (Mark one.) ^ Yes ^ No Section 5: Recipients Failin¢ to Fulfill Obligations (Do not complete this section if you completed it on another MBAF submitted to U~EU. ) 33. During the period January 1, 2004 through December 31, 2004, dtd your orgamzatton have any rectpients who failed to report as by Minn. Stat § 1167.993 and § 1167.994? (Mark one. ) ^ Yes (Indicate the name of each recipient failing to report and the value of subsidy or financial assistance awarded to that j recipient. Attach additional pages if necessary.) Name of recipient Type of subsidy or assistance (See Ouestions 24 & 23.) Value of subsidy or assistance ^ No Did your organization have any recipients who failed to achieve any goals or fulfill any other obligations under an agreement signed on or after January 1, 2004, that were required to be fulfilled by the time of this report? (Mark one. } ^ Yes (Complete the remainder of this section.) ^ No (Stop here and submit form to DEED.) • For questions 35-39: Provide the following information for each recipient failing to fulfill goals or any other terms of an agreement that were to be attained by the time of reporting. (Attach additional 35. Information on recipient and agreement: Name of recipient in default Type of subsidy or assistance Initial value of subsidy or assistance Street address of recipient City/Zip code of recipient Outstanding value of subsidy or assistance 36. Reason(s) for default (Mark all that apply. ): ^ recipient ceased operation ^ recipient relocated to a different community ^ recipient was unable to fill vacant positions ^ other (Sped reason.) Minnesota Business Assistance Form (02/01/05) Page 4 of 5 Dept of Employment and Economic Development