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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 /> • Name of recipient in default: <br /> Street address of recipient: Type of subsidy or assistance: <br /> City/Zip code of recipient: <br /> Initial value of subsidy or assistance: Outstanding Value of subsidy or assistance: <br /> 36.Reason(s)for default(Mark all that apply.): <br /> ❑recipient ceased operation ❑recipient relocated to a different community <br /> ❑recipient was unable to fill vacant positions ❑other(Specify reason.): <br /> 37.To date,has the recipient fulfilled its repayment obligation? (Mark one.) <br /> ❑Yes ❑No,recipient has begun to repay the assistance. ❑No,recipient has not begun to repay the assistance. <br /> 38.Has the agreement been amended to extend the recipient's deadline for fulfilling its obligations? (Mark one.) <br /> ❑Yes 0 N <br /> 39.Describe the steps being taken to bring recipient into compliance or recoup the subsidy: <br /> Return your completed MBAF(s) by April 1,2013 <br /> EITHER <br /> • Mail To: <br /> Minnesota Business Assistance Report <br /> Minnesota Department of Employment and Economic Development—Analysis and Evaluation <br /> 1st National Bank Building <br /> 332 Minnesota Street, Suite E200 <br /> St.Paul,Minnesota 55101-1351 <br /> OR <br /> Fax To: <br /> (651)215-3841 <br /> Next year,please submit your information using our online form. <br /> • <br /> Minnesota Business Assistance Form(12/10/12) Page 5 of 5 Dept.of Employment and Economic Development <br />