OMB Approval No. 2506-0145 (exp. 11/30/2009)

**U. S. Department of Housing**

**and Urban Development**

Office of Community Planning

and Development

### 

**Annual Progress Report (APR)**

**for**

**Supportive Housing Program**

**Shelter Plus Care**

**and**

**Section 8 Moderate Rehabilitation**

**for Single Room Occupancy**

**Dwellings (SRO) Program**

**Public reporting burden** for this collection of information is
estimated to average 33 hours per response, including the time for
reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection
of information. This agency may not conduct or sponsor, and a person is
not required to respond to, a collection of information unless that
collection displays a valid OMB control number.

General Instructions

**Purpose.** The Annual Progress Report (APR) is a reporting tool that
HUD uses to track program progress and accomplishments and inform the
Department's competitive process for homeless assistance funding.

**Filing Requirements.** Recipients of HUD's homeless assistance
[**grants must submit 2 APR'S to HUD within 90 days** **after the end of
each operating year. **]{.underline} One copy of the report must be
submitted to the Community Planning and Development (CPD) Division
Director in the local HUD Field Office responsible for managing the
grant. The other copy must be submitted to HUD Headquarters, Department
of Housing and Urban Development, Attn: APR Data Editor, Room 7262, 451
7^th^ Street, SW, Washington, DC. 20410. Failure to submit an APR will
delay receiving grant funds and may result in a determination of lack of
capacity for future funding. An APR must be submitted for each operating
year in which HUD funding is provided.

Grantees that received SHP funding for new construction, acquisition, or
rehabilitation are required to operate their facilities for 20 years.
They must submit an APR 90 days after the end of the first operating
year and every year throughout the 20 years.

A separate report must be submitted for each HUD grant received. For
Shelter Plus Care (S+C), a separate APR must be submitted for each S+C
component.

For those grantees receiving an extension, a separate report covering
that period must be submitted (see Extension below).

**Recordkeeping.** Grantees must collect and maintain information on
each participant in order to complete an APR. Optional worksheets are
attached. The worksheets may be used to record information manually or
to design a computerized system to store and tabulate the information.
The worksheets should not be submitted to HUD with the APR.

**Organization of the Report.** The APR is organized in the following
manner:

**Part I: Project Progress.** This portion of the report describes the
progress in moving homeless persons to self-sufficiency, documenting
services received, listing project goals, and accounting for beds/units.

> **Part II: Financial Information.** This portion of the report is
> completed by all grantees receiving funding under SHP, S+C, and SRO.

**Final Assembly of Report.** After the entire report is assembled,
number every page sequentially. Mark any questions that do not apply to
your program with "N/A" for not applicable. (See Special Instructions
for SSO Projects below.)

**Definitions of Client/Household Types.** Each client/household type is
defined below. Note that a client's client/household type should be
based on the client's age and/or household composition *at the program
entry date closest to the start of the operating year*.

> **Families --** A family is a household composed of two or more
> related persons, at least one of who is a child accompanied by an
> adult or a juvenile parent.
>
> **Singles not in Families** -- Persons not accompanied by children,
> including pregnant women not accompanied by other children and
> unaccompanied youth, are singles not in families. When two adults or
> two unaccompanied youth present together for services, each person
> should be counted in singles not in families.. Clients' household
> status should be determined based on their household composition at
> the program entry date closest to the start of the operating year.
> This means that pregnant women expected to give birth during their
> program stay should still be counted as singles not in families.
>
> **Adults in Families** -- Within a family, an adult is any person 18
> years of age or older. For the purposes of APR reporting, the
> determination of whether a person is an adult in family should be made
> based on their age and household composition at the program entry date
> closest to the start of the operating year.
>
> **Children in Families** -- Children in Families are defined as
> children under the age of 18 accompanied by one or more adults
> (parent, relative or guardian). Children in families also include both
> a juvenile parent and the parent's child(ren). For the purposes of APR
> reporting, the determination of whether a person is a child in family
> should be made based on their age and household composition at the
> program entry date closest to the start of the operating year. For
> example, clients who are less than 18 years of age on the first day of
> the operating year or at program entry (if they entered during the
> operating year) should be counted as children even if they turn 18
> during the course of the operating year.
>
> **Persons in Families** -- Persons in families includes adults in
> families and children in families.

**Other Key Definitions.** The following terms are used in the APR. As
indicated, in some cases, terms are applied differently depending on
whether the funding is from SHP, S+C, or SRO.

> **Chronically homeless person --** HUD defines a chronically homeless
> person as "an unaccompanied homeless individual with a disabling
> condition who has either been continuously homeless for a year or more
> **OR** has had at least four (4) episodes of homelessness in the past
> three (3) years." To be considered chronically homeless, a person must
> have been on the streets or in an emergency shelter (i.e., not in
> transitional housing) during these stays.
>
> HUD's definition of a chronically homeless person is based on the
> following components:

-   **Unaccompanied homeless individual:** an unaccompanied homeless
    individual has the same characteristics of a Single not in a Family
    (described above).

-   **Disabling condition:** see the instructions under disabling
    condition (below) to determine whether a client is disabled.

> **Did not leave the program** -- This term refers to clients who were
> in the program on the last day of the operating year.
>
> **Disabling condition** - HUD defines a disabling condition as: (1) A
> disability as defined in Section 223 of the Social Security Act; (2) a
> physical, mental, or emotional impairment which is (a) expected to be
> of long-continued and indefinite duration, (b) substantially impedes
> an individual's ability to live independently, and (c) of such a
> nature that such ability could be improved by more suitable housing
> conditions; (3) a developmental disability as defined in section 102
> of the Developmental Disabilities Assistance and Bill of Rights Act;
> (4) the disease of acquired immunodeficiency syndrome or any
> conditions arising from the etiological agency for acquired
> immunodeficiency syndrome; or (5) a diagnosable substance abuse
> disorder.
>
> **Entered the program** -- Entered the program refers to the first day
> a client receives services. For a residential program, this date would
> represent the first day of residence in the program's housing. For
> services, this date may represent the day of program enrollment, the
> day a service was provided, or the first date of a period of
> continuous participation in a service (e.g., daily, weekly, or
> monthly).
>
> For S+C and SRO programs, the program entry date is the date that the
> participant starts to receive rental assistance. For S+C, services
> provided prior to this point are recognized as necessary for
> outreach/enrollment and are eligible to count as match.
>
> An **Extension APR** applies to SHP and S+C grantees that requested
> and received an extension of their grant term from the HUD field
> office. The only difference between an APR for the extension period
> and the regular APR (besides the amount of time covered) is the
> signature page. Grantees should circle "yes" to indicate the APR is
> for an extension period and circle the operating year for which the
> report is an extension. For example, if the grantee is extending year
> 3, the grantee should submit an APR as usual for year 3 and submit
> another APR for the extension period, indicating the second is an
> extension and also circling year 3 on the signature page.
>
> **Grantee** means a direct recipient of the HUD award.
>
> **Left the program --** Left the program refers to the last day a
> client receives services. For a residential program, this date would
> represent the last day of residence in the program's housing. For
> services, the exit date may represent the last day a service was
> provided or the last date of a period of continuous service. If a
> client leaves the program temporarily (e.g., for a hospitalization)
> but is expected to return within 30 days, do not count that client as
> having left the program.
>
> For S+C programs, the program exit date refers to the date the
> participant stops receiving rental assistance and is not expected to
> return to S+C assisted housing. If the participant returns to S+C
> assisted housing within 90 days, the person should not be considered
> as exiting from the program. If the person returns to S+C assisted
> housing after 90 days, that person is considered a new participant.
> The worksheet is designed to capture this information.
>
> **Match** for S+C is the value of supportive services received by
> participants in the S+C project which, in the aggregate, must at least
> equal the value of the S+C rental assistance provided over the life of
> the project. For SHP, match is cash used to provide the grantee's
> portion of acquisition, rehabilitation, new construction, operations
> and supportive services expenses.
>
> **Operating year --** For SHP programs, the first operating year
> begins after development activities for acquisition, rehabilitation,
> and new construction are complete, after a copy of the Certificate of
> Occupancy is sent to the local HUD office, and when the first
> participant is accepted into the project. For projects without
> acquisition, rehabilitation, or new construction, the operating start
> date begins when the grantee accepts the first participant. For
> dedicated HMIS projects, the operating year begins when any eligible
> cost included in the approved project budget is incurred. For S+C
> (SRA, PRA and TRA components), the first operating year begins on the
> date HUD signs the grant agreement. For S+C/SRO and for Sec. 8 SRO,
> the first operating year begins with the effective date of the Housing
> Assistance Payments (HAP) Contract.
>
> To determine which operating year to circle on the APR cover page,
> begin counting from the initial grant operating start date and include
> renewal grants. For example, a project receiving an initial grant for
> three years and a renewal grant for two years would circle years 1, 2,
> and 3 respectively on the APR cover sheet for the initial grant and
> would circle 4 and 5 respectively for the renewal grant. For any
> future renewal grants, the grantee would begin by circling 6 on the
> APR cover sheet.
>
> **Participants** -- The term participant refers to Singles not in
> Families and Adults in Families as defined above. Participant does not
> include children or caregivers who live with the adults assisted.
>
> **Project Sponsor** means the organization responsible for carrying
> out the daily operation of the project, if the organization is an
> entity other than the grantee.

**[Special Instructions for Supportive Service Only (SSO)
Programs]{.underline}.** SSO grantees should complete all questions,
unless a written agreement has been reached with the field office
concerning which questions can be answered using estimates, or in rare
instances, skipped.

Below is an example of how information could be derived in a large,
single-service SSO project:

A grantee/sponsor staff member could be assigned to collect information
from the organizations housing the participants. The staff person would
contact these individual organizations to request information regarding
the persons in that facility that use the service. For participants
living on the street, the grantee/project sponsor may provide estimates.

Information could be collected for each participant or for participants
receiving services at a point-in-time. If estimates or point-in-time
counts are used, the method used must be described in the APR and the
documentation kept on file.

As with all projects funded under HUD's homelessness assistance grants,
grantees operating SSO projects are expected to complete
**[all]{.underline}** APR questions that are applicable to them. Note
that all projects have been awarded funds as a result of responding to
the program goals of assisting homeless persons obtain/remain in
permanent housing and increase their skills and income. The APR
documents their progress in meeting these goals.

In some circumstances field offices and grantees may sign a written
agreement concerning questions that can be answered using estimates, or
in rare instances, skipped. See the special instructions below for
reporting on special types of projects, such as outreach only projects,
projects providing services to children only, and transportation,
medical, dental, and other single, short-duration service projects.

SSO programs are a third priority for local HMIS implementation,
following emergency shelters, transitional housing programs, outreach
programs, and permanent supportive housing programs. Once SSO programs
are included in the HMIS, SSO grantees will be able to answer all APR
questions using their HMIS data. SSO grantees that are not yet
participating in HMIS will need to collect data to answer the APR
questions using the special instructions provided above.

# Outreach Only Projects. Projects which are solely devoted to street outreach and connection to housing and services are not required to track participants beyond their contact with persons on the street. It is sufficient for these projects to enter information on questions 1-10 (skipping questions 11-13 and 17). Estimates for questions 5-9 are allowed, given that participants may be reluctant to answer personal questions.

Answering the questions will demonstrate that the grantee is serving the
appropriate number of people, providing basic demographic information
for Congress, demonstrating that homeless persons are being served,
demonstrating the types of housing participants are connected to, and
the type of services they are receiving.

# Hotline Projects. Hotline services are similar to outreach only projects, but contact between grantee and participant is often of very short duration - people enter and leave the program nearly simultaneously. It is sufficient for these projects to answer questions 1-5 (skipping 4), 10, and 14-19 (skipping 17).

Projects Providing Services To Children Only. **Projects that provide
child care, after school care, counseling for children, etc. make an
important contribution toward moving a family out of homelessness. While
the main focus of the project is providing services to the children, it
is the adults who are reported on in questions 6-16 of the APR. Like all
other projects, this type is also targeted toward getting the families
into housing and increasing the families' incomes.** Grantees may skip
question 9; all other questions should be answered (except 17).

# Transportation, Medical, Dental, and Other Single, Short-Duration Service Projects. Some grantees provide a single service of fairly short duration focused ONLY indirectly on assisting homeless persons to obtain/remain in permanent housing and increase their skills and incomes. It is sufficient for these projects to enter information on questions 1-10 and 14-19 (question 17 may be skipped). However, with transportation services, it is unreasonable to think that someone would have to give their age, race, and ethnicity to a bus driver to get a ride a few blocks.

For these services, provide a narrative, which gives the number of rides
given during the operating year, and provides estimates on the above
statistics based on the population that utilizes the service.

**[Special Instructions For Safe Haven (SH) Projects]{.underline}.**
Grantees should report on all participants served during the operating
year. Note: this is a change from prior instructions where grantees were
instructed to report on the first 25 participants served.

**[Special Instructions for Homeless Management Information System
(HMIS) Projects]{.underline}.** HMIS grantees should fill out the cover
sheet of the APR, Part II Financial Information, and the HMIS Activities
section.

> ***THIS PAGE - TO BE COMPLETED BY ALL GRANTEES***

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| N |               |     |               |      |              |    |
| o |               |     |               |      |              |    |
+---+---------------+-----+---------------+------+--------------+----+
| P |               |     |               |      |              |    |
| r |               |     |               |      |              |    |
| e |               |     |               |      |              |    |
| v |               |     |               |      |              |    |
| i |               |     |               |      |              |    |
| o |               |     |               |      |              |    |
| u |               |     |               |      |              |    |
| s |               |     |               |      |              |    |
| G |               |     |               |      |              |    |
| r |               |     |               |      |              |    |
| a |               |     |               |      |              |    |
| n |               |     |               |      |              |    |
| t |               |     |               |      |              |    |
| N |               |     |               |      |              |    |
| u |               |     |               |      |              |    |
| m |               |     |               |      |              |    |
| b |               |     |               |      |              |    |
| e |               |     |               |      |              |    |
| r |               |     |               |      |              |    |
| s |               |     |               |      |              |    |
| f |               |     |               |      |              |    |
| o |               |     |               |      |              |    |
| r |               |     |               |      |              |    |
| t |               |     |               |      |              |    |
| h |               |     |               |      |              |    |
| i |               |     |               |      |              |    |
| s |               |     |               |      |              |    |
| p |               |     |               |      |              |    |
| r |               |     |               |      |              |    |
| o |               |     |               |      |              |    |
| j |               |     |               |      |              |    |
| e |               |     |               |      |              |    |
| c |               |     |               |      |              |    |
| t |               |     |               |      |              |    |
| : |               |     |               |      |              |    |
+---+---------------+-----+---------------+------+--------------+----+
|   |               |     |               |      |              |    |
+---+---------------+-----+---------------+------+--------------+----+
|   |               |     |               |      |              |    |
+---+---------------+-----+---------------+------+--------------+----+
|   |               |     |               |      |              |    |
+---+---------------+-----+---------------+------+--------------+----+
|   |               |     |               |      |              |    |
+---+---------------+-----+---------------+------+--------------+----+
|   |               |     |               |      |              |    |
+---+---------------+-----+---------------+------+--------------+----+

Check the component for the program on which you are reporting.

+----------------------+-------------------------+--------------------+
| **Supportive Housing | **Shelter Plus Care     | **Section 8        |
| Program (SHP)**      | (S+C)**                 | Moderate           |
|                      |                         | Rehabilitation**   |
+----------------------+-------------------------+--------------------+
| Transitional Housing | Tenant-based Rental     | Single Room        |
|                      | Assistance (TRA)        | Occupancy          |
+----------------------+-------------------------+--------------------+
| Permanent Housing    | Sponsor-based Rental    | (Sec. 8 SRO)       |
| for Homeless Persons | Assistance (SRA)        |                    |
| with Disabilities    | Project-based Rental    |                    |
|                      | Assistance (PRA)        |                    |
+----------------------+-------------------------+--------------------+
| Safe Haven           | Single Room Occupancy   |                    |
|                      | (SRO)                   |                    |
+----------------------+-------------------------+--------------------+
| Innovative           |                         |                    |
| Supportive Housing   |                         |                    |
+----------------------+-------------------------+--------------------+
| Supportive Services  |                         |                    |
| Only                 |                         |                    |
|                      |                         |                    |
| HMIS                 |                         |                    |
+----------------------+-------------------------+--------------------+

Summary of the project: (One or two sentences with a description of
population, number served and accomplishments this operating year)

+-----------------------------------------------------------------------+
| Name & Title of the Person who can answer questions about this        |
| report: Phone: (include area code)                                    |
+-----------------------------------------------------------------------+
| Address: Fax Number: (include area code)                              |
|                                                                       |
| E-mail Address                                                        |
+-----------------------------------------------------------------------+
| I hereby certify that all the information stated herein is true and   |
| accurate.                                                             |
|                                                                       |
| **Warning:** HUD will prosecute false claims and statements.          |
| Conviction may result in criminal and/or civil penalties. (18 U.S.C.  |
| 1001, 1010, 1012; 31 U.S.C. 3729, 3802)                               |
+-----------------------------------------------------------------------+
| Name & Title of Authorized Grantee Official: Signature & Date:        |
|                                                                       |
| X                                                                     |
+-----------------------------------------------------------------------+
| Name and Title of Authorized Project Sponsor Official: Signature &    |
| Date:                                                                 |
|                                                                       |
| X                                                                     |
+-----------------------------------------------------------------------+

***PART I. TO BE COMPLETED BY ALL GRANTEES (EXCEPT HMIS)***

## SSO GRANTEES, PLEASE SEE SPECIAL INSTRUCTIONS ON PAGE 3 OF THE APR

**Part I: Project Progress**

**1. Projected Level of Persons to be served at a given point in time.
(This information comes from the most recent CoC application.)**

+---+-----------------------------------+-------+-------+-------+------+
|   | Projected Level                   | N     | N     | N     | Nu   |
|   |                                   | umber | umber | umber | mber |
|   |                                   | of    | of    | of    | of   |
|   |                                   | Si    | A     | Chi   | Fami |
|   |                                   | ngles | dults | ldren | lies |
|   |                                   | Not   | in    |       |      |
|   |                                   |       | Fam   | in    |      |
|   |                                   | in    | ilies | Fam   |      |
|   |                                   | Fam   |       | ilies |      |
|   |                                   | ilies |       |       |      |
+---+-----------------------------------+-------+-------+-------+------+
| a | Persons to be served at a given   |       |       |       |      |
| \ | point in time                     |       |       |       |      |
| . |                                   |       |       |       |      |
+---+-----------------------------------+-------+-------+-------+------+

**2. Persons Served during the operating year.**

+---+-----------------------------------+-------+-------+-------+------+
|   |                                   | N     | N     | N     | Nu   |
|   |                                   | umber | umber | umber | mber |
|   |                                   | of    | of    | of    | of   |
|   |                                   | Si    | A     | Chi   | Fami |
|   |                                   | ngles | dults | ldren | lies |
|   |                                   | Not   | in    | in    |      |
|   |                                   | in    | Fam   | Fam   |      |
|   |                                   | Fam   | ilies | ilies |      |
|   |                                   | ilies |       |       |      |
+---+-----------------------------------+-------+-------+-------+------+
| a | Number on the first day of the    |       |       |       |      |
| \ | operating year                    |       |       |       |      |
| . |                                   |       |       |       |      |
+---+-----------------------------------+-------+-------+-------+------+
| b | Number entering program during    |       |       |       |      |
| \ | the operating year                |       |       |       |      |
| . |                                   |       |       |       |      |
+---+-----------------------------------+-------+-------+-------+------+
| c | Number who left the program       |       |       |       |      |
| \ | during the operating year         |       |       |       |      |
| . |                                   |       |       |       |      |
+---+-----------------------------------+-------+-------+-------+------+
| d | Number in the program on the last |       |       |       |      |
| \ | day of the operating year         |       |       |       |      |
| . |                                   |       |       |       |      |
|   | (a + b - c) = d                   |       |       |       |      |
+---+-----------------------------------+-------+-------+-------+------+

**Explanatory notes:**

See Definitions of Client/Household Types in the General Instructions
above to determine which clients should be counted as Singles Not in
Families, Adults in Families, and Children in Families. Note that this
table does not account for changes in client/household type that may
occur during the course of the operating year. Instead, each client
should be assigned a single client/household type based on the client's
age and/or household composition *at the program entry date closest to
the start of the operating year*. In this way, each client is counted
only once in the table.

Use the following graphic and explanations to determine who should be
counted in rows a-d:

![](media/image1.png){width="4.60625in" height="2.191666666666667in"}

**a. Number on the first day of the operating year:** This row includes
all clients who entered the program before the first day of the
operating year and did not leave the program until after the first day
of the operating year.

**b. Number entering the program during the operating year:** This row
includes all clients who entered the program on or after the first day
of the operating year, up to and including the last day of the operating
year. For clients with multiple program entry dates, use the entry date
closest to the start of the operating year. Do not count the client more
than once even if he/she entered the program more than once during the
operating year.

**c. Number who left during the operating year:** This row includes all
clients who left the program on or after the first day of the operating
year, up to and including the last day of the operating year. For
clients with multiple program exit dates, use the exit date closest to
the end of the operating year. Do not count the client more than once
even if he/she exited the program more than once during the operating
year.

**d. Number in the program on the last day of the operating year:** This
row includes all clients who were in the program as of the first day of
the operating year or who entered during the operating year *and* who
did not leave during the operating year. The number of clients or
families in the program on the last day of the operating year is
calculated based on the responses to rows 2a through 2c. For each
column, add the number of clients or families in row 2a to the number of
clients or families in row 2b and subtract the number of clients or
families in row 2c. Therefore, 2d = 2a + 2b -- 2c.

**3. Project Capacity.**

  ----- ------------------------------------ ---------- ---------- ---------- ----------
                                             Number of  Number of  Number of  Number of
                                             Singles    Adults in  Children   Families
                                             Not in     Families   in         
                                             Families              Families   

  a\.   Number on the last day (from 2d,                                      
        columns 1 and 4)                                                      

  b\.   Number proposed in application (from                                  
        1a, columns 1 and 4)                                                  

  c\.   Capacity Rate (divide a by b) = %    \%                               \%
  ----- ------------------------------------ ---------- ---------- ---------- ----------

**Explanatory Notes:**

Row b refers to the most recent CoC application for which the program is
reporting.

**4. Non-homeless persons.** This question is to be completed for
Section 8 SRO projects.

  --------------------------------------------------------------- -------
  How many income-eligible non-homeless persons were housed by    
  the SRO program during the operating year?                      

  --------------------------------------------------------------- -------

5.  **Age and Gender.** Of those who **entered** the project during the
    operating year, how many people are in the following age and gender
    categories?

  ------------------------------------ ----- ---------- ---------- ----------
  **Single Persons (from 2b, column          Age        Male       Female
  1)**                                                             

                                       a\.   62 and                
                                             over                  

                                       b\.   51-61                 

                                       c\.   31-50                 

                                       d\.   18-30                 

                                       e\.   17 and                
                                             under                 

                                                                   

  **Persons in Families (from 2b,      f\.   62 and                
  columns 2 & 3)**                           over                  

                                       g\.   51 - 61               

                                       h\.   31 - 50               

                                       i\.   18 - 30               

                                       j\.   13-17                 

                                       k\.   6-12                  

                                       l\.   1-5                   

                                       m\.   Under 1               
  ------------------------------------ ----- ---------- ---------- ----------

**Explanatory Notes:**

This question refers only to Singles not in Families and Persons in
Families who entered the program during the operating year. Only clients
who meet these criteria can be counted in this table. The total number
of clients reported under Single Persons should be equal to the number
reported in question 2b, column 1. The total number of clients reported
under Persons in Families should be equal to the sum of columns 2 and 3
in question 2b.

Answer questions 6 - 10 only for **participants who
[entered]{.underline} the project during the operating year** (from 2b,
columns 1 & 2). The term **participant** means Singles not in Families
and Adults in Families. It does not include children or caregivers.
NOTE: The total for questions, 7, 8 and 10 below should be the same;
respond to each of those questions for all participants. Some of the
questions listed throughout the APR will be asking information for
individuals who are **[chronically homeless]{.underline}**.

**6a. Veterans Status**. A veteran is anyone who has ever been on active
military duty status.

  ------------------------------------------------------------- ---------
  How many participants were veterans?                          

  ------------------------------------------------------------- ---------

**6b.** **Chronically homeless person**. An unaccompanied homeless
individual with a disabling condition who has either been continuously

homeless for a year or more OR has had at least four (4) episodes of
homelessness in the past three (3) years. To be considered

chronically homeless a person must have been on the streets or in an
emergency shelter (i.e. not transitional housing) during

these stays. For further discussion of the definition of chronic
homelessness, see Other Key Definitions under the General Instructions
above.

  ------------------------------------------------------------- ---------
  How many participants were **chronically homeless**           
  individuals?                                                  

  ------------------------------------------------------------- ---------

**7. Ethnicity**. How many participants are in the following ethnic
categories?

  ----- -------------------------------------------------------- ---------
  a\.   Hispanic or Latino                                       

  b\.   Non-Hispanic or Non-Latino                               
  ----- -------------------------------------------------------- ---------

**Explanatory Notes:**

Each participant should be listed in only one category. The total number
of participants in this table should equal the number of participants in
question 2b, columns 1 and 2.

**8. Race.** How many participants are in the following racial
categories?

  ----- --------------------------------------------------------- ---------
  a\.   American Indian/Alaskan Native                            

  b\.   Asian                                                     

  c\.   Black/African American                                    

  d\.   Native Hawaiian/Other Pacific Islander                    

  e\.   White                                                     

  f\.   American Indian/Alaskan Native & White                    

  g\.   Asian & White                                             

  h\.   Black/African American & White                            

  i\.   American Indian/Alaskan Native & Black/African American   

  j\.   Other Multi-Racial                                        
  ----- --------------------------------------------------------- ---------

**Explanatory Notes:**

Each participant should be listed in only one category. A participant
whose race does not correspond to categories a through i should be
counted in j, Other Multi Racial. The total number of participants in
this table should equal the number of participants in question 2b,
columns 1 and 2. If using HMIS data, you may combine HMIS race response
categories to generate the APR response categories.

**9a. Special Needs.** How many participants have the following?
Participants may have more than one.

If so, count them in [all]{.underline} applicable categories. For each
condition, also indicate the number

that were **chronically homeless.**

All Chronic

  ----- ------------------------------------------------- -------- --------
  a\.   Mental illness                                             

  b\.   Alcohol abuse                                              

  c\.   Drug abuse                                                 

  d\.   HIV/AIDS and related diseases                              

  e\.   Developmental disability                                   

  f\.   Physical disability                                        

  g\.   Domestic violence                                          

  h\.   Other (please specify)                                     
  ----- ------------------------------------------------- -------- --------

**9b**. How many of the participants are disabled?

**Explanatory Notes:**

To determine which participants meet HUD's definition of "disabled," see
"Disabling Condition" under Other Key Definitions in the General
Instructions.

**10. Prior Living Situation.** How many participants slept in the
following places in the week prior to entering the project? (For each
participant, choose one place. The total number of participants in the
"All" column should equal the number of participants in question 2b,
columns 1 and 2). Also, indicate how many **chronically homeless**
participants slept in the following places. (Choose one)

All Chronic

  ----- ------------------------------------------------- -------- --------
  a\.   Non-housing (street, park, car, bus station,               
        etc.)                                                      

  b\.   Emergency shelter                                          

  c\.   Transitional housing for homeless persons                  

  d\.   Psychiatric facility\*                                     

  e\.   Substance abuse treatment facility\*                       

  f\.   Hospital\*                                                 

  g\.   Jail/prison\*                                              

  h\.   Domestic violence situation                                

  i\.   Living with relatives/friends                              

  j\.   Rental housing                                             

  k\.   Other (please specify)                                     
  ----- ------------------------------------------------- -------- --------

\*If a participant came from an institution (psychiatric facility,
substance abuse treatment facility, hospital, or jail), but was there
less than 30 days and was living on the street or in emergency shelter
before entering the treatment facility, he/she should be counted in
either the street or shelter category, as appropriate.

Complete questions 11 - 15 for all **participants** **who
[left]{.underline} during the operating year** (from 2c, columns 1 and
2). The term participant means single persons and adults in families. It
does not include children or caregivers. The term **chronically homeless
person** means an unaccompanied homeless individual with a disabling
condition who has either been continuously homeless for a year or more
OR has had at least four (4) episodes of homelessness in the past three
(3) years. To be considered chronically homeless a person must have been
on the streets or in an emergency shelter (i.e. not transitional
housing) during these stays.

**11. Amount and Source of Monthly Income at Entry and at Exit.** Of
those participants who left during the operating year, how many

participants were at each monthly income level and with each source of
income? Also, please place the monthly income level and each

source of income for **chronically homeless persons** in the second
column of each chart. The number of participants in Chart A and B

should be the same.

**All Chronic** **All Chronic**

  ----- ----------- ------ ----- -- ----- ---------------------------- ----- -----
        A. Monthly                        C. Income Sources At               
        Income at                         **Entry**                          
        **Entry**                                                            

  a\.   No income                   a\.   Supplemental Security Income       
                                          (SSI)                              

  b\.   \$1-150                     b\.   Social Security Disability         
                                          Income (SSDI)                      

  c\.   \$151 -                     c\.   Social Security                    
        \$250                                                                

  d\.   \$251-                      d\.   General Public Assistance          
        \$500                                                                

  e\.   \$501 -                     e\.   Temporary Aid to Needy             
        \$1,000                           Families (TANF)                    

  f\.   \$1001-                     f\.   State Children's Health            
        \$1500                            Insurance Program (SCHIP)          

  g\.   \$1501-                     g\.   Veterans Benefits                  
        \$2000                                                               

  h\.   \$2001 +                    h\.   Employment Income                  

                                    i\.   Unemployment Benefits              

                                    j\.   Veterans Health Care               

                                    k\.   Medicaid                           

                                    l\.   Food Stamps                        

                                    m..   Other (please specify)             

                                    n\.   No Financial Resources             
  ----- ----------- ------ ----- -- ----- ---------------------------- ----- -----

**All Chronic** **All Chronic**

  ----- ------------ ------ ----- -- ----- ---------------------------- ----- -----
        B. Monthly                         D. Income Sources at               
        Income at                          **Exit**                           
        **Exit**                                                              

  a\.   No income                    a\.   Supplemental Security Income       
                                           (SSI)                              

  b\.   \$1-150                      b\.   Social Security Disability         
                                           Income (SSDI)                      

  c\.   \$151 -                      c\.   Social Security                    
        \$250                                                                 

  d\.   \$251- \$500                 d\.   General Public Assistance          

  e\.   \$501 -                      e\.   Temporary Aid to Needy             
        \$1,000                            Families (TANF)                    

  f\.   \$1001-                      f\.   State Children's Health            
        \$1500                             Insurance Program (SCHIP)          

  g\.   \$1501-                      g\.   Veterans Benefits                  
        \$2000                                                                

  h\.   \$2001 +                     h\.   Employment Income                  

                                     i\.   Unemployment Benefits              

                                     j\.   Veterans Health Care               

                                     k\.   Medicaid                           

                                     l\.   Food Stamps                        

                                     m\.   Other (please specify)             

                                     n\.   No Financial Resources             
  ----- ------------ ------ ----- -- ----- ---------------------------- ----- -----

Explanatory Notes:

**Table A:** Monthly income at entry refers to the participant's monthly
income on the day he/she entered the program (i.e., on the program entry
date or as close as possible to that day). You should not report on
income received before entering the program or income received during
the program stay.

**Table B:** Monthly income at exit refers to the participant's monthly
income on the day he/she left the program (i.e., on the program exit
date or as close as possible to that day). You should not report on
income received during the program stay.

**Table C:** Income sources at entry refers to the participant's sources
of income on the day he/she entered the program (i.e., on the program
entry date or as close as possible to that day). You should not report
on sources of income received before entering the program or income
received during the program stay. Participants with no income at the
time of program entry should be reported in category n, No Financial
Resources.

**Table D:** Income sources at exit refers to the participant's sources
of income on the day he/she left the program (i.e., on the program exit
date or as close as possible to that day). You should not report on
sources of income received during the program stay. Participants with no
income at the time of program exit should be reported in category n, No
Financial Resources.

**12a.** Of those participants who **[left]{.underline}** during the
operating year (from 2c, columns 1 and 2), how many were in the project
for the following

> lengths of time? Also, please place the length of stay for
> **chronically homeless** persons who **[left]{.underline}** during the
> operating year in the second column.

All Chronic

  ----- --------------------------------------------------- ------ ------
  a\.   Less than 1 month                                          

  b\.   1 to 2 months                                              

  c\.   3 - 6 months                                               

  d\.   7 months - 12 months                                       

  e\.   13 months - 24 months                                      

  f\.   25 months - 3 years                                        

  g\.   4 years - 5 years                                          

  h\.   6 years - 7 years                                          

  i\.   8 years - 10 years                                         

  j\.   Over 10 years                                              
  ----- --------------------------------------------------- ------ ------

**Explanatory Notes:**

Compute each participant's length of stay using the participant's
program entry date and program exit date. If the participant has only
one program exit date during the operating year, calculate length of
stay by subtracting the program entry date from the program exit date.
If the participant has multiple program exit dates during the operating
year, calculate the length of stay for each program stay (by subtracting
the program entry date from the program exit date for each program stay)
and add them together to produce a cumulative length of stay. Each
participant should be associated with only one length of stay category.
The total number of participants in the first column ("All") should
equal the number of participants in question 2c, columns 1 and 2.

**12b. Length of Stay in Program.** For those participants who did
**[not leave]{.underline}** during the operating year (from 2d, columns
1 and 2), how long have they been in the project? Also, please place the
length of stay for **chronically homeless persons** who did **[not
leave]{.underline}** during the operating year in the second column.

All Chronic

  ----- --------------------------------------------------- ------ ------
  a\.   Less than 1 month                                          

  b\.   1 to 2 months                                              

  c\.   3 - 6 months                                               

  d\.   7 months - 12 months                                       

  e\.   13 months - 24 months                                      

  f\.   25 months - 3 years                                        

  g\.   4 years - 5 years                                          

  h\.   6 years - 7 years                                          

  i\.   8 years - 10 years                                         

  j\.   Over 10 years                                              
  ----- --------------------------------------------------- ------ ------

**Explanatory Notes:**

Compute each participant's length of stay using the participant's
program entry date and the last day of the operating year. To calculate
length of stay, subtract the program entry date from the last day of the
operating year. Each participant should be associated with only one
length of stay category. The total number of participants in the first
column ("All") should equal the number of participants in question 2d,
columns 1 and 2.

**13. Reasons for Leaving.** Of those participants who
**[left]{.underline}** the project during the operating year (from 2c,
columns 1 and 2), how many left for the following reasons? If a
participant left for multiple reasons, ***include [only]{.underline} the
primary reason***. The total number of participants in the first column
("All") should equal the number of participants in question 2c, columns
1 and 2. Also, please place the **primary** reason for **chronically
homeless persons** who **[left]{.underline}** the project during the
operating year in the second column.

All Chronic

  ----- --------------------------------------------------- ------ ------
  a\.   Left for a housing opportunity before completing           
        program                                                    

  b\.   Completed program                                          

  c\.   Non-payment of rent/occupancy charge                       

  d\.   Non-compliance with project                                

  e\.   Criminal activity / destruction of property /              
        violence                                                   

  f\.   Reached maximum time allowed in project                    

  g\.   Needs could not be met by project                          

  h\.   Disagreement with rules/persons                            

  i\.   Death                                                      

  j\.   Other (please specify)                                     

  k\.   Unknown/disappeared                                        
  ----- --------------------------------------------------- ------ ------

**14. Destination.** Of those participants who **[left]{.underline}**
during the operating year (from 2c, columns 1 and 2), how many left for
the following destination? Also, please place the destination of
**chronically homeless persons** who **[left]{.underline}** during the
operating year in the second column.

All Chronic

  -------------------- ----- ------------------------------------ ----- -----
  PERMANENT (a-h)      a\.   Rental house or apartment (no              
                             subsidy)                                   

                       b\.   Public Housing                             

                       c\.   Section 8                                  

                       d\.   Shelter Plus Care                          

                       e\.   HOME subsidized house or apartment         

                       f\.   Other subsidized house or apartment        

                       g\.   Homeownership                              

                       h\.   Moved in with family or friends            

  TRANSITIONAL (i-j)   i\.   Transitional housing for homeless          
                             persons                                    

                       j\.   Moved in with family or friends            

  INSTITUTION (k-m)    k\.   Psychiatric hospital                       

                       l\.   Inpatient alcohol or other drug            
                             treatment facility                         

                       m\.   Jail/prison                                

  EMERGENCY SHELTER    n\.   Emergency shelter                          
  (n)                                                                   

  OTHER (o-q)          o\.   Other supportive housing                   

                       p\.   Places not meant for human                 
                             habitation (e.g. street)                   

                       q\.   Other (please specify)                     

  UNKNOWN              r\.   Unknown                                    
  -------------------- ----- ------------------------------------ ----- -----

**Explanatory Notes:**

Identify each participant's destination upon leaving the program using
the categories provided. The response categories combine "destination"
(e.g., rental house or apartment, public housing, homeownership, etc.)
and "tenure" (e.g., permanent, transitional, etc.). Consider both
destination and tenure to determine the most appropriate response, and
be sure to look at all of the response categories before making a
selection. The table below provides a brief description of each response
category.

Enter the number of participants under each destination category in
either the first column of the table or in both columns if the
participant is chronically homeless. Only one reason for leaving should
be recorded per participant. The total number of participants in the
first column ("All") should equal the number of participants in question
2c, columns 1 and 2.

  ------------------------------------------------------------------------------
  **Tenure**           **Destination**      **Description**
  -------------- ----- -------------------- ------------------------------------
  Permanent      a\.   Rental house or      Participant is moving to an
                       apartment (no        apartment or house without any
                       subsidy)             subsidy.

                 b\.   Public housing       Participant is moving to a public
                                            housing unit.

                 c\.   Section 8            Participant will use a housing
                                            choice voucher (formerly known as a
                                            Section 8 voucher) to rent a house
                                            or apartment.

                 d\.   Shelter Plus Care    Participant is moving to a unit
                                            funded by the Shelter Plus Care
                                            program (e.g., TBA, SRA, PRA,
                                            Section 8 SRO).

                 e\.   HOME subsidized      Participant is moving to a unit with
                       house or apartment   rental assistance provided by the
                                            HOME program (tenant-based or
                                            project-based assistance).

                 f\.   Other subsidized     Participant is moving to a unit
                       house or apartment   subsidized by some program other
                                            than public housing, housing choice
                                            voucher program (formerly Section
                                            8), Shelter Plus Care, or HOME.

                 g\.   Homeownership        Participant is moving to a unit that
                                            he/she has purchased.

                 h\.   Moved in with family Participant is moving in with family
                       or friends           or friends and expects to live there
                                            for 90 days or more.

  Transitional   i\.   Transitional housing Participant is moving into a unit
                       for homeless people  funded by a transitional housing
                                            program for homeless people (e.g.,
                                            transitional housing funded through
                                            the Supportive Housing Program).

                 j\.   Moved in with family Participant is moving in with family
                       or friends           or friends and expects to live there
                                            less than 90 days.

  Institution    k\.   Psychiatric hospital Participant is moving to a
                                            psychiatric hospital.

                 l\.   Inpatient alcohol or Participant is moving to an
                       other drug treatment inpatient alcohol or drug treatment
                       facility             facility.

                 m     Jail/Prison          Participant is moving to a jail or
                                            prison.

  Emergency      n\.   Emergency shelter    Participant is moving to an
  Shelter                                   emergency shelter for homeless
                                            people.

  Other          o\.   Other supportive     Participant is moving into
                       housing              supportive housing that does not
                                            correspond to any of the permanent
                                            housing categories (a-h) and is not
                                            transitional housing for homeless
                                            people (i), such as Section 811
                                            housing.\*

                 p\.   Places not meant for Participant is moving to a place not
                       human habitation     meant for human habitation, such as
                                            a car, park, sidewalk, or abandoned
                                            building.

                 q\.   Other (please        Participant is moving to a place
                       specify)             that does not correspond to any of
                                            the categories above (a-p).

  Unknown        r\.   Unknown              This response category should be
                                            used if you are unsure about where
                                            the participant is moving or if the
                                            participant has disappeared and
                                            there is no way to find out where
                                            he/she is.
  ------------------------------------------------------------------------------

*\*HUD encourages programs to limit the use of the "Other Supportive
Housing" APR response category. Programs should report destinations to
housing that are permanent or transitional in APR categories (a) through
(h) or in categories (i) through (j), respectively. Exits to emergency
shelters should be reported in category (n).*

**15. Supportive Services.** Of those participants who
**[left]{.underline}** during the operating year (from 2, columns 1 and
2), how many received the following supportive services during their
time in the project? Also, please place the supportive services received
for **chronically homeless** participants who **[left]{.underline}**
during the operating year in the second column. Participants may have
received multiple services and all services should be reported in the
table.

All Chronic

  ----- ---------------------------------------------------- ------ ------
  a\.   Outreach                                                    
  a.                                                                

  b\.   Case management                                             

  c\.   Life skills (outside of case management)                    

  d\.   Alcohol or drug abuse services                              

  e\.   Mental health services                                      

  f\.   HIV/AIDS-related services                                   

  g\.   Other health care services                                  

  h\.   Education                                                   

  i\.   Housing placement                                           

  j\.   Employment assistance                                       

  k\.   Child care                                                  

  l\.   Transportation                                              

  m\.   Legal                                                       

  n\.   Other (please specify)                                      
  ----- ---------------------------------------------------- ------ ------

**16. [Overall Program Goals]{.underline}**. Under objectives, list your
measurable objectives for this operating year (from your application,
Technical

> Submission, or APR) for each of the three goals listed below. Under
> Progress, describe your progress in meeting the objectives.
>
> Under Next Operating Year's Objectives, specify the measurable
> objectives for the next operating year.

**a. Residential Stability**

Objectives:

Progress:

Next Operating Year's Objectives:

**b. Increased Skills or Income**

Objectives:

Progress:

Next Operating Year's Objectives:

**c. Greater Self-determination**

Objectives:

Progress:

Next Operating Year's Objectives:

**17. Beds**. SHP recipients answer 17a. S+C recipients answer 17b. SRO
recipients answer 17c. ***(SHP-SSO projects do***

***not complete this question)***

a\. **SHP**. How many beds were included in the application approved for
*this* project under 'Current Level' and under 'New Effort'?

> How many of these New Effort beds were actually in place at the end of
> the operating year?
>
> Current Level New Effort New Effort in Place
>
> Number of Beds:

b\. **S+C.** How many beds and dwelling units were being assisted with
project funds at the end of the operating year?

> (Include beds for all participants, other family members, and care
> givers.)
>
> Number of Beds:
>
> Number of Dwelling Units:
>
> c\. **SRO.** How many dwelling units were being assisted at the end of
> the operating year?
>
> (Include units occupied by "in place" non-homeless persons who qualify
> for assistance.)
>
> Number of Dwelling Units:

**Part II: Financial Information**

**18. Supportive Services.**

For [Supportive Housing (SHP)]{.underline}, this exhibit provides
information to HUD on how SHP funding for supportive services was spent
**during the operating year.** Enter the amount of SHP funding spent on
these supportive services. Include HMIS costs under "Other".

For [Shelter Plus Care (S+C)]{.underline}, this exhibit tracks the
supportive services match requirement. Specify the value of supportive
services from all sources that can be counted as match that all homeless
persons received **during the operating year. (**S+C grantees should
keep documentation on file, including source, amount, and type of
supportive services.)

For [Section 8 SRO]{.underline}, this exhibit provides information to
HUD on the value of supportive services received by homeless persons
**during the operating year.**

+----+---------------------------------------+-------------------------+
|    | Supportive Services                   | Dollars                 |
+----+---------------------------------------+-------------------------+
| a  | Outreach                              |                         |
| \. |                                       |                         |
+----+---------------------------------------+-------------------------+
| b  | Case management                       |                         |
| \. |                                       |                         |
+----+---------------------------------------+-------------------------+
| c  | Life skills (outside of case          |                         |
| \. | management)                           |                         |
+----+---------------------------------------+-------------------------+
| d  | Alcohol and drug abuse services       |                         |
| \. |                                       |                         |
+----+---------------------------------------+-------------------------+
| e  | Mental health services                |                         |
| \. |                                       |                         |
+----+---------------------------------------+-------------------------+
| f  | AIDS-related services                 |                         |
| \. |                                       |                         |
+----+---------------------------------------+-------------------------+
| g  | Other health care services            |                         |
| \. |                                       |                         |
+----+---------------------------------------+-------------------------+
| h  | Education                             |                         |
| \. |                                       |                         |
+----+---------------------------------------+-------------------------+
| i  | Housing placement                     |                         |
| \. |                                       |                         |
+----+---------------------------------------+-------------------------+
| j  | Employment assistance                 |                         |
| \. |                                       |                         |
+----+---------------------------------------+-------------------------+
| k  | Child care                            |                         |
| \. |                                       |                         |
+----+---------------------------------------+-------------------------+
| l  | Transportation                        |                         |
| \. |                                       |                         |
+----+---------------------------------------+-------------------------+
| m  | Legal                                 |                         |
| \. |                                       |                         |
+----+---------------------------------------+-------------------------+
| n  | Other (please specify)                |                         |
| \. |                                       |                         |
+----+---------------------------------------+-------------------------+
| o  | **TOTAL** (Sum of a through n)        |                         |
| \. |                                       |                         |
+----+---------------------------------------+-------------------------+
|    |                                       |                         |
+----+---------------------------------------+-------------------------+
|    | Cumulative amount of match provided   |                         |
|    | to date for the                       |                         |
|    |                                       |                         |
|    | **Shelter Plus Care Program** under   |                         |
|    | this grant                            |                         |
+----+---------------------------------------+-------------------------+

**19. Supportive Housing Program: Leasing, Supportive Services,
Operating Costs, HMIS Activities and Administration**

All grantees receiving funding under the Supportive Housing Program must
complete these charts each operating year. For **expansion projects**:
If SHP grant funds are for the expansion of a pre-existing homeless
facility, only the people and expenditures for the additional expansion
may be included, as in the original application or any grant amendments.
Documentation of resources used is not required to be submitted with
this report but should be kept on file for possible inspection by HUD
and Auditors. Do not include any expenditures made before the SHP grant
was executed.

**Summary of Expenditures**. Enter the amount of SHP grant funds and
cash match expended during the operating year for each activity. This
table should add up both horizontally and vertically. The SHP supportive
services total should be the same as the SHP supportive services in
Question 18.

+---+------------------+---------------+----------------+--------------+
|   |                  | SHP Funds     | Cash Match     | Total        |
|   |                  |               |                | Expenditures |
+---+------------------+---------------+----------------+--------------+
| a | Leasing          |               |                |              |
| \ |                  |               |                |              |
| . |                  |               |                |              |
+---+------------------+---------------+----------------+--------------+
| b | Supportive       |               |                |              |
| \ | Services         |               |                |              |
| . |                  |               |                |              |
+---+------------------+---------------+----------------+--------------+
| c | Operating Costs  |               |                |              |
| \ |                  |               |                |              |
| . |                  |               |                |              |
+---+------------------+---------------+----------------+--------------+
| d | HMIS Activities  |               |                |              |
| \ |                  |               |                |              |
| . |                  |               |                |              |
+---+------------------+---------------+----------------+--------------+
| e | Administration   |               |                |              |
| \ |                  |               |                |              |
| . |                  |               |                |              |
+---+------------------+---------------+----------------+--------------+
| f | ##### Total      |               |                |              |
| \ |                  |               |                |              |
| . |                  |               |                |              |
+---+------------------+---------------+----------------+--------------+

**Note:** Payments of principal and interest on any loan or mortgage may
not be shown as an operating expense.

**Sources of Cash Match**. Enter the sources of cash identified in the
Cash Match column, above, in the following categories. Use additional
sheets, as necessary.

  ----- -------------------------------------------------- ---------------
                                                           Amount

  a\.   Grantee/project sponsor cash                       

  b\.   Local government (please specify)                  

                                                           

                                                           

                                                           

  c\.   State government (please specify)                  

                                                           

                                                           

                                                           

  d\.   Federal government (please specify)                

        Community Development Block Grant (CDBG)           

                                                           

                                                           

  e\.   Foundations (please specify)                       

                                                           

                                                           

                                                           

  f\.   Private cash resources (please specify)            

                                                           

                                                           

                                                           

  g\.   Occupancy charge / fees                            

  h\.   **Total**                                          
  ----- -------------------------------------------------- ---------------

**20. Supportive Housing Program: Acquisition, Rehabilitation, and New
Construction**

All grantees that received SHP funds for acquisition, rehabilitation, or
new construction must complete these charts in the year one APR

only. This exhibit will demonstrate to HUD that the grantee has
contributed enough cash to at least equally match the amount of SHP
funds spent for acquisition, rehabilitation, or new construction.
Documentation that matching funds were provided is not required to be
submitted with this report but should be kept on file for possible
inspection by HUD and Auditors.

**Summary of Expenditures.** Enter the amount of SHP grant funds and
cash match expended during the operating year for each activity.

  ----- -------------------- -------------- ---------------- ---------------
                             SHP Funds      Cash Match       Total
                                                             Expenditures

  a\.   Acquisition                                          

  b\.   Rehabilitation                                       

  c\.   New construction                                     

  d\.   **Total**                                            
  ----- -------------------- -------------- ---------------- ---------------

**Cash Match.** Enter the sources of cash identified in the Cash Match
column, above, in the following categories. Use

additional sheets, as necessary.

  ----- ------------------------------------------- ----------------------
                                                    Amount

  a\.   Grantee/project sponsor cash                

  b\.   Local government (please specify)           

                                                    

                                                    

                                                    

  c\.   State government (please specify)           

                                                    

                                                    

                                                    

  d\.   Federal government (please specify)         

        Community Development Block Grant (CDBG)    

                                                    

                                                    

  e\.   Foundations (please specify)                

                                                    

                                                    

                                                    

  f\.   Private cash resources (please specify)     

                                                    

                                                    

                                                    

  g\.   Occupancy charge/ fees                      

  h\.   **Total**                                   
  ----- ------------------------------------------- ----------------------

***FOR HMIS ACTIVITIES ONLY***

21\. **For [Supportive Housing (SHP) -- HMIS Activities]{.underline}**

This exhibit provides information to HUD on how SHP-HMIS funding for
supportive services was spent **during the operating year.** Enter the
amount of SHP-HMIS funding spent on these activities.

+-----------------------------------------+----------------------------+
| ## HMIS Activities Only                 | ## Dollars                 |
+-----------------------------------------+----------------------------+
| ## Equipment                            | ##                         |
+-----------------------------------------+----------------------------+
| Central Server(s)                       |                            |
+-----------------------------------------+----------------------------+
| Personal Computers and Printers         |                            |
+-----------------------------------------+----------------------------+
| Networking                              |                            |
+-----------------------------------------+----------------------------+
| Security                                |                            |
+-----------------------------------------+----------------------------+
| ## Subtotal                             |                            |
+-----------------------------------------+----------------------------+
| ## Software                             |                            |
+-----------------------------------------+----------------------------+
| Software / User Licensing               |                            |
+-----------------------------------------+----------------------------+
| Software Installation                   |                            |
+-----------------------------------------+----------------------------+
| Support and Maintenance                 |                            |
+-----------------------------------------+----------------------------+
| Supporting Software Tools               |                            |
+-----------------------------------------+----------------------------+
| ######### Subtotal                      |                            |
+-----------------------------------------+----------------------------+
| ## Services                             |                            |
+-----------------------------------------+----------------------------+
| Training by Third Parties               |                            |
+-----------------------------------------+----------------------------+
| Hosting / Technical Services            |                            |
+-----------------------------------------+----------------------------+
| Programming: Customization              | ##                         |
+-----------------------------------------+----------------------------+
| Programming: System Interface           |                            |
+-----------------------------------------+----------------------------+
| Programming: Data Conversion            |                            |
+-----------------------------------------+----------------------------+
| Security Assessment and Setup           |                            |
+-----------------------------------------+----------------------------+
| On-line Connectivity (Internet Access)  |                            |
+-----------------------------------------+----------------------------+
| Facilitation                            |                            |
+-----------------------------------------+----------------------------+
| Disaster and Recovery                   |                            |
+-----------------------------------------+----------------------------+
| **Subtotal**                            |                            |
+-----------------------------------------+----------------------------+
| ## Personnel                            |                            |
+-----------------------------------------+----------------------------+
| Project Management / Coordination       |                            |
+-----------------------------------------+----------------------------+
| Data Analysis                           |                            |
+-----------------------------------------+----------------------------+
| Programming                             |                            |
+-----------------------------------------+----------------------------+
| Technical Assistance and Training       |                            |
+-----------------------------------------+----------------------------+
| Administrative Support Staff            |                            |
+-----------------------------------------+----------------------------+
| **Subtotal**                            |                            |
+-----------------------------------------+----------------------------+
| ## HMIS Space and Operations            |                            |
+-----------------------------------------+----------------------------+
| Space Costs                             |                            |
+-----------------------------------------+----------------------------+
| Operational Costs                       |                            |
+-----------------------------------------+----------------------------+
| **Total**                               |                            |
+-----------------------------------------+----------------------------+
|                                         |                            |
+-----------------------------------------+----------------------------+

**Describe any problems and/or changes implemented during the operating
year.**

**Technical Assistance and Recommendations**

Based on your experience during the last year, are there any areas in
which you need technical advice or assistance? If so, please describe.

**Persons Served Worksheet -** HUD Annual Progress Report

Collection of the Protected Personal Information (PPI) on this form is
done with the knowledge or consent of the clients. The PPI is only used
for the following purpose:

Accurate completion of the Annual Progress Report (APR) for the
Continuum of Care (CoC) Homeless Assistance Program in which the client
is enrolled.

**This worksheet is optional and is intended to help you collect
information needed to complete the Annual Progress Report. Instructions
and Codes follow. Do not submit this worksheet to HUD.**

<table>
<colgroup>
<col style="width: 3%" />
<col style="width: 16%" />
<col style="width: 8%" />
<col style="width: 6%" />
<col style="width: 4%" />
<col style="width: 11%" />
<col style="width: 11%" />
<col style="width: 9%" />
<col style="width: 11%" />
<col style="width: 7%" />
<col style="width: 4%" />
<col style="width: 5%" />
</colgroup>
<tbody>
<tr class="odd">
<td>No.</td>
<td>Name</td>
<td>Relationship</td>
<td>Entry Date</td>
<td><p>Exit</p>
<p>Date</p></td>
<td><p>Number of Months in Project (calculate)</p>
<p>12a</p></td>
<td><p>Number of Months in Project –Participant did not leave
(calculate)</p>
<p>12b</p></td>
<td><p>New Participant</p>
<p>(Y / N)</p></td>
<td><p>Non-Homeless (SRO Only)</p>
<p>(Y / N)</p>
<p>4</p></td>
<td><p>Date of Birth</p>
<p>5a</p></td>
<td><p>Age</p>
<p>5b</p></td>
<td><p>Gender</p>
<p>(M/F)</p>
<p>5c</p></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>

**Persons Served Worksheet** (continued)

Collection of the Protected Personal Information (PPI) on this form is
done with the knowledge or consent of the clients. The PPI is only used
for the following purpose:

Accurate completion of the Annual Progress Report (APR) for the
Continuum of Care (CoC) Homeless Assistance Program in which the client
is enrolled.

**Do not submit this worksheet to HUD**

<table>
<colgroup>
<col style="width: 3%" />
<col style="width: 7%" />
<col style="width: 8%" />
<col style="width: 7%" />
<col style="width: 6%" />
<col style="width: 8%" />
<col style="width: 10%" />
<col style="width: 7%" />
<col style="width: 8%" />
<col style="width: 10%" />
<col style="width: 10%" />
<col style="width: 11%" />
</colgroup>
<tbody>
<tr class="odd">
<td>No.</td>
<td><p>Veterans Status (Y/N)</p>
<p>6a</p></td>
<td><p>Chronically Homeless (Y/N)</p>
<p>6b</p></td>
<td><p>Ethnicity</p>
<p>(code)</p>
<p>7</p></td>
<td><p>Race</p>
<p>(code)</p>
<p>8</p></td>
<td><p>Special Needs</p>
<p>(code)</p>
<p>9a</p></td>
<td><p>Special Needs</p>
<p>(code)</p>
<p>9b</p></td>
<td><p>Prior Living</p>
<p>Situation</p>
<p>(code )</p>
<p>10</p></td>
<td><p>Monthly Income At Project Entry</p>
<p>11a</p></td>
<td><p>Monthly Income</p>
<p>At Project Exit</p>
<p>11b</p></td>
<td><p><u>Income Sources</u></p>
<p>At Entry</p>
<p>(code)</p>
<p>11c</p></td>
<td><p><u>Income Sources</u></p>
<p>At Exit</p>
<p>(code)</p>
<p>11d</p></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
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</table>

**Persons Served Worksheet (continued)**

Collection of the Protected Personal Information (PPI) on this form is
done with the knowledge or consent of the clients. The PPI is only used
for the following purpose:

Accurate completion of the Annual Progress Report (APR) for the
Continuum of Care (CoC) Homeless Assistance Program in which the client
is enrolled.

**Do not submit this worksheet to HUD**

+---+---------+------+---------+-------------------------------------+
| N | Reason  | Des  | Sup     | Notes                               |
| o | for     | tina | portive |                                     |
| . | Leaving | tion | S       |                                     |
|   |         |      | ervices |                                     |
|   | Program | (c   | (code)  |                                     |
|   | (code)  | ode) |         |                                     |
|   |         |      | 15      |                                     |
|   | 13      | 14   |         |                                     |
+---+---------+------+---------+-------------------------------------+
|   |         |      |         |                                     |
+---+---------+------+---------+-------------------------------------+
|   |         |      |         |                                     |
+---+---------+------+---------+-------------------------------------+
|   |         |      |         |                                     |
+---+---------+------+---------+-------------------------------------+
|   |         |      |         |                                     |
+---+---------+------+---------+-------------------------------------+
|   |         |      |         |                                     |
+---+---------+------+---------+-------------------------------------+
|   |         |      |         |                                     |
+---+---------+------+---------+-------------------------------------+
|   |         |      |         |                                     |
+---+---------+------+---------+-------------------------------------+
|   |         |      |         |                                     |
+---+---------+------+---------+-------------------------------------+
|   |         |      |         |                                     |
+---+---------+------+---------+-------------------------------------+
|   |         |      |         |                                     |
+---+---------+------+---------+-------------------------------------+
|   |         |      |         |                                     |
+---+---------+------+---------+-------------------------------------+
|   |         |      |         |                                     |
+---+---------+------+---------+-------------------------------------+
|   |         |      |         |                                     |
+---+---------+------+---------+-------------------------------------+
|   |         |      |         |                                     |
+---+---------+------+---------+-------------------------------------+
|   |         |      |         |                                     |
+---+---------+------+---------+-------------------------------------+
|   |         |      |         |                                     |
+---+---------+------+---------+-------------------------------------+
|   |         |      |         |                                     |
+---+---------+------+---------+-------------------------------------+
|   |         |      |         |                                     |
+---+---------+------+---------+-------------------------------------+

**Instructions and Codes for Persons Served Worksheet**

The use of this worksheet is optional. It was designed to help you
collect information on participants needed to complete the Annual
Progress Report. If the worksheet is updated as participants move in and
move out of your project, most of the information required for
completion will be contained in the worksheet. Do not submit this
worksheet with the APR.

For projects that serve families, HUD only requires reporting on the
number of children served, and the age and gender of these children.
Only name, relationship, date of birth, and age on the worksheet need to
be completed for children. Assign the adults a number, but not each
family member. Use this number to transfer to the other pages of the
worksheet.

Beginning with number 4, the numbers in the columns refer to the
questions on the APR form. If any questions are answered with "Other,"
please enter the specific "Other" answer for inclusion in the APR.

**Participant Number**. This column allows you

to either number participants consecutively or to

assign a case number. One number should be

assigned to each adult.

**Name**. Names of persons will not be reported to

HUD. The use of names is for your record keeping

convenience.

**Relationship**. Enter the appropriate relationship.

Examples include: Self, Head of household, Spouse,

Child.

**Entry Date.** Enter date participant [entered the]{.underline}

[project]{.underline}. Usually this will be the date of actual

physical move-in for a housing project.

**Exit Date.** Enter date participant [left the project]{.underline}.

Usually this will be the date the participant

physically moved out for a housing project. Do not

include a participant who temporarily left the project

and is expected to return in less than 90 days (e.g.,

hospitalization).

4\. **Income-eligible Non-homeless in SRO**. The SRO

> program allows assistance to units occupied by
>
> Section 8 income-eligible persons residing at the SRO prior to
> rehabilitation. For SRO projects only, indicate whether the
> participant is an income-eligible, non-homeless person (Y) or not (N).
> SHP and S+C projects should skip this item.

5a. **Date of Birth.** Enter date of birth including month, day, and
year.

5b. **Age.** Enter age at entry.

5c. **Gender.** Enter appropriate letter for gender.

> M-Male F- Female.

6a. **Veterans Status**. Indicate if the participant is a

veteran. *Please note: A veteran is anyone who*

*has ever been on active military duty status for*

*the United States.*

6b*.* **Chronically homeless person**. Indicate the

number of participants that are chronically

homeless.

7\. **Ethnicity.** Enter appropriate letter for ethnic group.

> a\. Hispanic or Latino
>
> b\. Non-Hispanic or Non-Latino

8\. **Race.** Enter appropriate letter for race.

> a\. American Indian or Alaskan Native
>
> b\. Asian

c\. Black or African-American

> d\. Native Hawaiian or Other Pacific Islander

e\. White

f\. American Indian/Alaskan Native & White

g\. Asian & White

h\. Black/African American & White

> i\. American Indian/Alaskan Native &
>
> Black/African American
>
> j\. Other Multi-Racial

9a. **Special Needs.** Enter the letter(s) for the

> category(ies) that describe the participant's disability(ies). (You
> may double count).

a\. Mental illness

b\. Alcohol abuse

c\. Drug abuse

d\. HIV/AIDS and related diseases

e\. Developmental disability

f\. Physical disabilities

g\. Domestic violence

h\. Other (please specify)

9b. Enter the number of participants with a disability.

10\. **Prior Living Situation.** Enter the letter that best describes
where the participant slept in the week prior to entering the project.
[Do not]{.underline} double count.

a\. Non-housing (street, park, car, bus station, etc.)

b\. Emergency shelter

c\. Transitional housing for homeless persons

d\. Psychiatric facility\*

e\. Substance abuse treatment facility\*

f\. Hospital\*

g\. Jail/prison\*

h\. Domestic violence situation

i\. Living with relatives/friends

j\. Rental housing

k\. Other (please specify)

\*If a participant came from an institution but

was there less than 30 days and was living on the

street or in an emergency shelter before entering the

facility, he/she should be counted in either the street

or shelter category, as appropriate.

Instruction Codes for Persons Served

**Worksheet** (continued)

11a.**Gross Monthly Income at Project Entry**.

Enter the amount of gross monthly income the participant is receiving at
entry into the project.

11b.**Gross Monthly Income at Project Exit.** Enter

the gross monthly income the participant is receiving when exiting the
project.

11c.**Income Sources Received at Project Entry.**

Enter all types of assistance the participant is receiving at entry to
the project.

a\. Supplemental Security Income (SSI)

b\. Social Security Disability Insurance (SSDI)

c\. Social Security

d\. General Public Assistance

e\. Temporary Aid Needy Families (TANF)

f\. State Children's Health Insurance Program (SCHIP)

g\. Veterans benefits

h\. Employment income

i\. Unemployment benefits

j\. Veterans Health Care

k\. Medicaid

l\. Food Stamps

m\. Other (please specify)

n\. No Financial Resources

11d.**Income Sources Received at Project Exit**.

Enter all types of income the participant is receiving at project exit.
(Use codes as in 11c.)

12a **Length in Stay in Program**. Calculated item.

(See Entry Date and Exit Date above.)

12b. **Length of Stay in Program**. (Participant did

not leave during the operating year. How long

have they been in the project?)

13\. **Reason for Leaving Project.** Enter the primary

> reason why the participant left the project. (Complete only for
> participants who left the project and are not expected to return
> within 90 days.

a\. Left for a housing opportunity before

completing the program

b\. Completed program

c\. Non-payment of rent/occupancy charge

d\. Non-compliance with project

> e\. Criminal activity/destruction of property/ violence
>
> f\. Reached maximum time allowed in project
>
> g\. Needs could not be met by project
>
> h\. Disagreement with rules/persons
>
> i\. Death
>
> j\. Other (please specify)
>
> k\. Unknown/disappeared

14\. **Destination.** Enter the destination of those

leaving the project.

**Permanent:**

> a\. Rental house or apartment (no subsidy)
>
> b\. Public Housing
>
> c\. Section 8
>
> d\. Shelter Plus Care
>
> e\. HOME subsidized house or apartment
>
> f\. Other subsidized house or apartment
>
> g\. Homeownership
>
> h\. Moved in with family or friends

**Transitional:**

> i\. Transitional housing for homeless persons
>
> j\. Moved in with family or friends

**Institution:**

> k\. Psychiatric hospital.
>
> l\. Inpatient alcohol or drug treatment facility
>
> m\. Jail/prison

**Emergency:**

> n\. Emergency shelter

**Other:**

> o\. Other supportive housing.
>
> p\. Places not meant for human habitation
>
> (e.g., street)
>
> q\. Other (please specify)

**Unknown:**

> r\. Unknown
>
> 15\. **Supportive Services.** Enter [all]{.underline} types of
>
> supportive services the participant received during the time in the
> project.
>
> a\. Outreach
>
> b\. Case management
>
> c\. Life skills (outside of case management)
>
> d\. Alcohol or drug abuse services
>
> e\. Mental health services
>
> f\. HIV/AIDS-related services
>
> g\. Other health care services
>
> h\. Education
>
> i\. Housing placement
>
> j\. Employment assistance
>
> k\. Child care
>
> l\. Transportation
>
> m\. Legal
>
> n\. Other (please specify)