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<br /> <br />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 <br /> hourly value of any employer-provided health insurance for those jobs. (Only indicate job creation in full-time equivalents if you are <br /> unable to separate job creation into full- and part-time positions.) <br /> <br /> Full-time Part-time/ FTE (only if unable to <br /> Hourly Wage Job Seasonal/Temp. stated as FT/PT) Hourly Value of <br /> (excluding benefits) Creation Job Creation Job Creation Job Retention Health Insurance <br /> <br />less than $7.00 ________ ________ ________ ________ $________ <br /> <br />$7.00 to $8.99 ________ ________ ________ ________ $________ <br /> <br />$9.00 to $10.99 ________ ________ ________ ________ $________ <br /> <br />$11.00 to $12.99 ________ ________ ________ ________ $________ <br /> <br />$13.00 to $14.99 ________ ________ ________ ________ $________ <br /> <br />$15.00 and higher ________ ________ ________ ________ $________ <br /> <br />32. Has the recipient achieved all goals (see Question 33, 34 and 35) and fulfilled all obligations stipulated in the agreement (Mark one.) <br /> <br /> ‰ Yes ‰ No <br /> <br /> <br />Section 5: Recipients Failing to Fulfill Obligations <br />(Do not complete this section if you completed it on another MBAF submitted to DEED.) <br />33. During the period January 1, 2004 through December 31, 2004, did your organization have any recipients who failed to report as required <br /> by Minn. Stat. §116J.993 and §116J.994? (Mark one.) <br /> <br /> ‰ Yes (Indicate the name of each recipient failing to report and the value of subsidy or financial assistance awarded to that <br /> recipient. Attach additional pages if necessary.) <br /> <br />_____________________________________ ____________________________________________ _________________________ <br />Name of recipient Type of subsidy or assistance (See Questions 24 & 25.) Value of subsidy or assistance <br /> <br /> <br /> ‰ No <br /> <br />34. Did your organization have any recipients who failed to achieve any goals or fulfill any other obligations under an agreement signed on <br /> or after January 1, 2004, that were required to be fulfilled by the time of this report? (Mark one.) <br /> <br /> ‰ Yes (Complete the remainder of this section.) ‰ No (Stop here and submit form to DEED.) <br /> <br /> <br />For questions 35-39: Provide the following information for each recipient failing to fulfill goals or any other terms of an agreement that were <br />to be attained by the time of reporting. (Attach additional pages if necessary.) <br />35. Information on recipient and agreement: <br /> <br /> <br />__________________________________________ _______________________________ ______________________________ <br />Name of recipient in default Type of subsidy or assistance Initial value of subsidy or assistance <br /> <br /> <br />__________________________________________ _______________________________ ______________________________ <br />Street address of recipient City/Zip code of recipient Outstanding value of subsidy <br /> or assistance <br /> <br />36. Reason(s) for default (Mark all that apply.): <br /> <br /> ‰ recipient ceased operation ‰ recipient relocated to a different community <br /> <br /> ‰ recipient was unable to fill vacant positions ‰ other (Specify reason.) <br /> <br /> ___________________________________________ <br /> <br /> <br /> <br />Minnesota Business Assistance Form (02/01/05) Page 4 of 5 Dept. of Employment and Economic Development