DGS DSA 787

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Division of the State Architect | State of California

DISABILITY ACCESS & EDUCATION FUND ANNUAL REPORT

DGS DSA 787 | Published 12/29/2022

This form is for use by city, county, or city and county representatives for the annual reporting of fees collected and transmitted to the Division of the State Architect (DSA) for deposit into the Disability Access and Education Revolving Fund. This form is due by March 1 of each year and reports on the fee collection in the previous calendar year. Fee collection, transmission and reporting is a requirement under Government Code Section 4467.

CITY/COUNTY AND DEPARTMENT

Reporting City or County Name

Reporting Year

Department Name

Department Mailing Address

City

State

Zip Code

PREPARER’S INFORMATION

First Name

Last Name

Work Phone Number

Work Email

$1 FEE RATE COLLECTION INFORMATION


Total Fees Collected
Fees Distributed to DSA (30% of Total Fees Collected)
Fees Retained by Local Entity (70% of Total Fees Collected)

$4 FEE RATE COLLECTION INFORMATION


Total Fees Collected
Fees Distributed to DSA (10% of Total Fees Collected)
Fees Retained by Local Entity (90% of Total Fees Collected)

SPENDING INFORMATION


Dollar Amount Spent for Administrative Services (Maximum of 5% of fees retained)
Dollar Amount Spent to Increase CASp Services

List the activities undertaken to increase CASp services (e.g. funds spent for training or retaining a CASp on staff)


Dollar Amount Spent to Fund Programs to Facilitate Access Compliance

List the activities undertaken to facilitate access compliance (e.g. outreach materials and activities)


Dollar Amount of Financial Assistance Provided to Small Businesses for Accessibility Improvements
Number of Small Businesses that Obtained Financial Assistance for Accessibility Improvements
Dollar Amount Held Over (Not Distributed or Spent)

Explain any funds held over

Name

Title

Date

SUBMIT FORM & DOWNLOAD PDF

Once the form has been completed, select the Create PDF button below to submit the form to DSA. A copy of the form will be sent to the Preparer’s email address provided above.

If you have questions, please email dsacommunication@dgs.ca.gov

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