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> **Housing Opportunities for Persons With AIDS (HOPWA) Program**

**Annual Progress Report (APR)**

**Measuring Performance Outcomes**

**OMB Number 2506-0133 (Expiration Date: 12/31/2010)**

.

**Overview.** The Annual Progress Report (APR) provides annual
performance reporting on clients outputs and outcomes that enables an
assessment of grantee performance in achieving the housing stability
outcome measure. The APR fulfills statutory reporting requirements and
provides the grantee and HUD with the necessary information to assess
the overall performance and accomplishment of the grantee's program
activities under the approved goals and objectives.

HOPWA competitive grantees are required to submit an APR for each
operating year in which HOPWA grant funds were expended. Information on
each competitive grant is to be reported in a separate APR. Grantees
must complete Parts 1-5 on standard reporting elements. Grantees
approved for "Other Activities", as detailed in their grant agreement,
are requested to adapt the APR to report on their unique program
accomplishments.

These revisions contained within this edition are designed to accomplish
the following: (1) provide for an assessment of unmet need; (2)
streamline reporting sources and uses of leveraged resources; (3)
differentiate client outcomes for temporary/short-term and permanent
facility-based assistance ; (4) clarify indicators for Short-term
efforts and reducing the risk of homelessness; and (5) clarify
indicators for Access to Care and Support for this special needs
population.

In addition, grantees are requested to comply with the Federal Funding
Accountability and Transparency Act 2006 (Public Law 109-282), which
requires grant recipients to provide general information for all
entities (including contractors and sub-contractors) receiving \$25,000+
in federal funding.

**Table of Contents**

**PART 1. Grantee Summary**

**PART 2. Grantee Narrative and Performance Assessment**

**PART 3. Summary Overview of Grant Activities**

A. Information on Individuals, Beneficiaries, and Households

B. Budget and Grant Sources for Leveraging

C. Performance and Expenditure Information

**PART 4. Summary of Performance Outcomes**

**PART 5. Summary of Project Sponsor Information**

A. Project Sponsor Information

B. Housing Assistance

C. Facility-based Housing Assistance

D. Supportive Services

E. Certification of Continued Use for HOPWA Facility-based

Stewardship Units (ONLY)

**PART 6. Worksheet - Determining HOPWA Outcomes and Connections with
HMIS**

**Continued Use Periods**. Grantees that received HOPWA funding for new
construction, acquisition, or substantial rehabilitation are required to
operate their facilities for ten years for HOPWA-eligible beneficiaries.
If no further HOPWA funds are used to support the facility, in place of
filing the APR, the grantee must submit an Annual Certification of
Continued Project Operation throughout the required use periods. This
certification is included in Part 5F Certification of Continued Usage in
this APR. The required use period is three years if rehabilitation is
non-substantial.

**Record Keeping.** Names and other individual information must be kept
confidential, as required by 24 CFR 574.440. However, HUD reserves the
right to review the information used to complete this report for grants
management oversight purposes, except for recording any names and other
identifying information. **Information is reported in aggregate to HUD
without personal identification. Do not submit client or personal
information in data systems to HUD.**

In connection with the development of the Department's standards for
Homeless Management Information Systems (HMIS), universal data elements
are being collected for clients of [HOPWA-funded homeless assistance
projects]{.underline}. These project sponsor records would include:
Name, Social Security Number, Date of Birth, Ethnicity and Race, Gender,
Veteran Status, Disability Status, Residence Prior to Program Entry, Zip
Code of Last Permanent Address, Program Entry Date, Program Exit Date,
Unique Person Identification Number, and Household Identification
Number. These are intended to match the elements under HMIS. The HOPWA
program-level data elements include: Income and Sources, Non-Cash
Benefits, HIV/AIDS Status, Housing Support, Services Received, and
Housing Status or Destination at the end of the operating year. Other
suggested but optional elements are: Behavioral Health Status, Domestic
Violence, Employment, Education, General Health Status, Physical
Disability, Pregnancy Status, Reasons for Leaving, Veteran's
Information, and Children's Education. Other HOPWA projects sponsors may
also benefit from collecting these data elements.

**Operating Year.** The information contained in this APR should reflect
the grantee's operating year determined at the time the grant agreement
is signed. Project sponsor accomplishment information must coincide with
this operating year period. Any change requires the approval of HUD by
amendment, such as an extension for one additional year of operation. A
renewal grant start date would be coordinated with the close out of the
existing grant.

**Final Assembly of Report.** After the entire report is assembled,
please number each page sequentially.

**Filing Requirements.** Within 90 days of the completion of the
operating year, grantees must submit their completed APR to the CPD
Director in the grantee's State or Local HUD Office, and to the HOPWA
Program Office: Office of HIV/AIDS Housing, Room 7212, U.S. Department
of Housing and Urban Development, 451 Seventh Street SW, Washington,
D.C. 20410.

**Definitions**

**Adjustment for Duplication:** Enables the calculation of an
unduplicated output totals by accounting for the total number of
households or units that received more than one type of assistance in a
given service category.

**Administrative Costs:** Costs for general management, oversight,
coordination, evaluation, and reporting. By statute, grantee
administrative costs are limited to 3% of total grant award, to be
expended over the life of the grant. Project sponsor administrative
costs are limited to 7% of the portion of the grant amount they receive.

**Beneficiary:** Any individual who received HOPWA housing assistance
during the operating year and includes all members of the household
receiving assistance.

**HOPWA Eligible Person:** A low-income person with HIV/AIDS who
qualifies the household for HOPWA assistance. This person may be
considered "Head of Household." When the APR asks for information on
eligible individuals, report on this person only. Where there is more
than one person with HIV/AIDS in the household, the additional PWA(s),
would be considered a beneficiary(s).

**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 episodes of homelessness in
the past three years." For this purpose, the term "homeless" means "a
person sleeping in a place not meant for human habitation (e.g., living
on the streets) or in an emergency homeless shelter." This does not
include doubled-up or overcrowding situations.

**Disabling Condition:** A diagnosable substance use disorder, serious
mental illness, developmental disability, or chronic physical illness or
disability, including the co-occurrence of two or more of these
conditions. In addition, a disabling condition may limit an individual's
ability to work or perform one or more activities of daily living. An
HIV/AIDS diagnosis is considered a disabling condition.

**Extension:** In addition to the standard three-year grant term, an
*Extension APR* applies to grantees that requested and received the
one-year extension of their grant term from the HUD field office.

**Facility-Based Housing Assistance:** All eligible HOPWA Housing
expenditures for associated with supporting facilities including
community residences, SRO dwellings, short-term facilities,
project-based rental units, master leased units, and other housing
facilities approved by HUD.

**Grassroots Organization:** An organization headquartered in the local
community where it provides services; has a social services budget of
\$300,000 or less annually, and six or fewer full-time equivalent
employees. Local affiliates of national organizations are not considered
"grassroots."

**Household:** A single individual or a family composed of two or more
persons for which household incomes are used to determine eligibility
and for calculation of the resident rent payment. Caregivers and
non-beneficiaries who resided in the shared unit are not reported on in
the APR. The term is used for collecting data on changes in income,
changes in access to services, receipt of housing information services,
and outcomes on achieving housing stability.

**Housing Stability:** See Part 6: Worksheet definitions of stable and
unstable housing situations.

**In-kind Leveraged Resources:** These involve additional types of
support provided to assist HOPWA beneficiaries such as volunteer
services, materials, use of equipment and building space. The actual
value of the support can be the contribution of professional services,
based on customary rates for this specialized support, or actual costs
contributed from other leveraged resources. In determining a rate for
the contribution of volunteer time and services, use the rate
established in HUD notices, such as the rate of ten dollars per hour.
The value of any donated material, equipment, building, or lease should
be based on the fair market value at time of donation. Related
documentation can be from recent bills of sales, advertised prices,
appraisals, or other information for comparable property similarly
situated.

**Non-HOPWA Leveraged Sources:** Cash resources separate from the HOPWA
grant award and may include: CDBG, HOME, ESG, SHP, S+C, SRO Mod Rehab,
Housing Choice Vouchers (Section 8), PHA units, Supportive Housing for
Persons with Disabilities/Elderly (Section 811/202), Low Income Housing
Tax Credits (LIHTC), Historic Tax Credits, USDA Rural Housing Service,
Ryan White CARE Act programs, other federal programs HHS, VA, DOL, etc,
state funds, local government funds, and private philanthropy. While
other HOPWA funds may be used in conjunction with this grant, the
amounts are [not]{.underline} counted as leveraging for purposes of the
grant application selection or criteria, and performance is reported
under the applicable HOPWA grant.

**Operating Costs:** Applies to facility-based housing only, for
facilities that are currently open. Operating costs can include
day-to-day housing function and operation costs like utilities,
maintenance, equipment, insurance, security, furnishings, supplies and
salary for staff costs directly related to the housing project but not
staff costs for delivering services.

**Outcome:** The HOPWA assisted households who have been enabled to
establish or better maintain a stable living environment in housing that
is safe, decent, and sanitary, (per the regulations at 24 CFR
574.310(b)) and to reduce the risks of homelessness, and improve access
to HIV treatment and other health care and support. The goal that eighty
percent of HOPWA clients will maintain housing stability, avoid
homelessness, and access care by 2011.

**Output:** The number of units of housing or households that receive
HOPWA housing assistance during the operating year.

**Permanent Housing Placement:** A supportive housing service that helps
establish the household in the housing unit, including but not limited
to reasonable costs for security deposits not to exceed two months of
rent costs.

**Program Income:** Gross income directly generated from the use of
HOPWA funds, including repayments. See grant administration requirements
on program income for state and local governments at 24 CFR 85.25, or
for non-profits at 24 CFR 84.24.

**Stewardship Units:** Units developed with HOPWA, where HOPWA funds
were used for acquisition, new construction and rehabilitation, but no
longer receive operating subsidies. Report information for the units
subject to the three-year use agreement if rehabilitation is
non-substantial, and those subject to the ten-year use agreement if
rehabilitation is substantial.

**Housing Opportunities for Persons with AIDS (HOPWA)**

**Annual Progress Report -- Measuring Performance Outcomes**

**PART 1:** **Grantee Summary**

**OMB Number 2506-0133 (Expiration Date: 12/31/2010)**

As applicable, complete the following charts. Chart 1 requests general
grantee information. Chart 2 is in response to the Federal Funding and
Accountability and Transparency Act of 2006 (Public Law 109-282) which
requests that grant recipients provide information that will enable
federal agencies to establish a central website that makes available to
the public full disclosure of all entities (including all project
sponsors and other organizations) receiving \$25,000+ in federal
funding. *Note*: *Report all general information pertaining to project
sponsors in Part 5A: Summary of Project Sponsor Information.*

1\. Grantee Information

+-----------------------+----------+----+---+----+---+-------+--------------+
| **HUD Grant Number**  |          |    | * |    |   |       |              |
|                       |          |    | * |    |   |       |              |
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|                       |          |    | x |    |   |       |              |
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|                       |          |    | r |    |   |       |              |
+-----------------------+----------+----+---+----+---+-------+--------------+
| **Grantee Name**      |          |    | * |    |   |       |              |
|                       |          |    | * |    |   |       |              |
|                       |          |    | P |    |   |       |              |
|                       |          |    | a |    |   |       |              |
|                       |          |    | r |    |   |       |              |
|                       |          |    | e |    |   |       |              |
|                       |          |    | n |    |   |       |              |
|                       |          |    | t |    |   |       |              |
|                       |          |    | C |    |   |       |              |
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|                       |          |    | m |    |   |       |              |
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|                       |          |    | n |    |   |       |              |
|                       |          |    | y |    |   |       |              |
|                       |          |    | * |    |   |       |              |
|                       |          |    | i |    |   |       |              |
|                       |          |    | f |    |   |       |              |
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|                       |          |    |   |    |   |       |              |
|                       |          |    |   |    |   |       |              |
|                       |          |    |   |    |   |       |              |
|                       |          |    |   |    |   |       |              |
|                       |          |    |   |    |   |       |              |
|                       |          |    |   |    |   |       |              |
+-----------------------+----------+----+---+----+---+-------+--------------+
| **Type of HOPWA       |          |    |   |    |   |       |              |
| Grant**               |          |    |   |    |   |       |              |
|                       |          |    |   |    |   |       |              |
| Competitive           |          |    |   |    |   |       |              |
|                       |          |    |   |    |   |       |              |
| Formula               |          |    |   |    |   |       |              |
+-----------------------+----------+----+---+----+---+-------+--------------+
| **Business Address**  |          |    |   |    |   |       |              |
+-----------------------+----------+----+---+----+---+-------+--------------+
| **City, State, Zip,   |          |    |   |    |   |       |              |
| County**              |          |    |   |    |   |       |              |
|                       |          |    |   |    |   |       |              |
|                       |          |    |   |    |   |       |              |
|                       |          |    |   |    |   |       |              |
+-----------------------+----------+----+---+----+---+-------+--------------+
| **Employer            |          |    | * |    |   |       |              |
| Identification Number |          |    | * |    |   |       |              |
| (EIN) or**            |          |    | D |    |   |       |              |
|                       |          |    | U |    |   |       |              |
| **Tax Identification  |          |    | N |    |   |       |              |
| Number (TIN)**        |          |    | & |    |   |       |              |
|                       |          |    | B |    |   |       |              |
|                       |          |    | r |    |   |       |              |
|                       |          |    | a |    |   |       |              |
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|                       |          |    | s |    |   |       |              |
|                       |          |    | t |    |   |       |              |
|                       |          |    | r |    |   |       |              |
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|                       |          |    |   |    |   |       |              |
|                       |          |    |   |    |   |       |              |
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|                       |          |    |   |    |   |       |              |
|                       |          |    |   |    |   |       |              |
|                       |          |    |   |    |   |       |              |
+-----------------------+----------+----+---+----+---+-------+--------------+
| **\*Congressional     |          |    |   |    |   |       |              |
| District of Address** |          |    |   |    |   |       |              |
+-----------------------+----------+----+---+----+---+-------+--------------+
| **\*Congressional     |          |    |   |    |   |       |              |
| District of Primary   |          |    |   |    |   |       |              |
| Service Area(s)**     |          |    |   |    |   |       |              |
|                       |          |    |   |    |   |       |              |
|                       |          |    |   |    |   |       |              |
+-----------------------+----------+----+---+----+---+-------+--------------+
| **\*Zip Code of       |          |    |   |    |   |       |              |
| Primary Service       |          |    |   |    |   |       |              |
| Area(s)**             |          |    |   |    |   |       |              |
|                       |          |    |   |    |   |       |              |
|                       |          |    |   |    |   |       |              |
+-----------------------+----------+----+---+----+---+-------+--------------+
| **City(ies) and       |          |    |   |    |   |       |              |
| County(ies) of        |          |    |   |    |   |       |              |
| Primary Service       |          |    |   |    |   |       |              |
| Area(s)**             |          |    |   |    |   |       |              |
|                       |          |    |   |    |   |       |              |
+-----------------------+----------+----+---+----+---+-------+--------------+
| **Organization's      |          | ** |   |    |   |       |              |
| Website Address**     |          | Do |   |    |   |       |              |
|                       |          | es |   |    |   |       |              |
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|                       |          | t? |   |    |   |       |              |
|                       |          | ** |   |    |   |       |              |
|                       |          | Y  |   |    |   |       |              |
|                       |          | es |   |    |   |       |              |
|                       |          | No |   |    |   |       |              |
|                       |          |    |   |    |   |       |              |
|                       |          | ** |   |    |   |       |              |
|                       |          | If |   |    |   |       |              |
|                       |          | ye |   |    |   |       |              |
|                       |          | s, |   |    |   |       |              |
|                       |          | e  |   |    |   |       |              |
|                       |          | xp |   |    |   |       |              |
|                       |          | la |   |    |   |       |              |
|                       |          | in |   |    |   |       |              |
|                       |          | in |   |    |   |       |              |
|                       |          | t  |   |    |   |       |              |
|                       |          | he |   |    |   |       |              |
|                       |          | n  |   |    |   |       |              |
|                       |          | ar |   |    |   |       |              |
|                       |          | ra |   |    |   |       |              |
|                       |          | ti |   |    |   |       |              |
|                       |          | ve |   |    |   |       |              |
|                       |          | s  |   |    |   |       |              |
|                       |          | ec |   |    |   |       |              |
|                       |          | ti |   |    |   |       |              |
|                       |          | on |   |    |   |       |              |
|                       |          | h  |   |    |   |       |              |
|                       |          | ow |   |    |   |       |              |
|                       |          | th |   |    |   |       |              |
|                       |          | is |   |    |   |       |              |
|                       |          | li |   |    |   |       |              |
|                       |          | st |   |    |   |       |              |
|                       |          | is |   |    |   |       |              |
|                       |          | a  |   |    |   |       |              |
|                       |          | dm |   |    |   |       |              |
|                       |          | in |   |    |   |       |              |
|                       |          | is |   |    |   |       |              |
|                       |          | te |   |    |   |       |              |
|                       |          | re |   |    |   |       |              |
|                       |          | d. |   |    |   |       |              |
|                       |          | ** |   |    |   |       |              |
+-----------------------+----------+----+---+----+---+-------+--------------+
| **Have you prepared   |          | ** |   |    |   |       |              |
| any evaluation        |          | Is |   |    |   |       |              |
| report?**             |          | t  |   |    |   |       |              |
|                       |          | he |   |    |   |       |              |
| *If so, please        |          | s  |   |    |   |       |              |
| indicate its location |          | po |   |    |   |       |              |
| on an Internet site   |          | ns |   |    |   |       |              |
| (url) or attach       |          | or |   |    |   |       |              |
| copy.*                |          | a  |   |    |   |       |              |
|                       |          | n  |   |    |   |       |              |
|                       |          | on |   |    |   |       |              |
|                       |          | pr |   |    |   |       |              |
|                       |          | of |   |    |   |       |              |
|                       |          | it |   |    |   |       |              |
|                       |          | o  |   |    |   |       |              |
|                       |          | rg |   |    |   |       |              |
|                       |          | an |   |    |   |       |              |
|                       |          | iz |   |    |   |       |              |
|                       |          | at |   |    |   |       |              |
|                       |          | io |   |    |   |       |              |
|                       |          | n? |   |    |   |       |              |
|                       |          | ** |   |    |   |       |              |
|                       |          | *  |   |    |   |       |              |
|                       |          | *Y |   |    |   |       |              |
|                       |          | es |   |    |   |       |              |
|                       |          | ** |   |    |   |       |              |
|                       |          | ** |   |    |   |       |              |
|                       |          | No |   |    |   |       |              |
|                       |          | ** |   |    |   |       |              |
|                       |          |    |   |    |   |       |              |
|                       |          | *  |   |    |   |       |              |
|                       |          | Pl |   |    |   |       |              |
|                       |          | ea |   |    |   |       |              |
|                       |          | se |   |    |   |       |              |
|                       |          | c  |   |    |   |       |              |
|                       |          | he |   |    |   |       |              |
|                       |          | ck |   |    |   |       |              |
|                       |          | if |   |    |   |       |              |
|                       |          | y  |   |    |   |       |              |
|                       |          | es |   |    |   |       |              |
|                       |          | a  |   |    |   |       |              |
|                       |          | nd |   |    |   |       |              |
|                       |          | a  |   |    |   |       |              |
|                       |          | f  |   |    |   |       |              |
|                       |          | ai |   |    |   |       |              |
|                       |          | th |   |    |   |       |              |
|                       |          | -b |   |    |   |       |              |
|                       |          | as |   |    |   |       |              |
|                       |          | ed |   |    |   |       |              |
|                       |          | or |   |    |   |       |              |
|                       |          | ga |   |    |   |       |              |
|                       |          | ni |   |    |   |       |              |
|                       |          | za |   |    |   |       |              |
|                       |          | ti |   |    |   |       |              |
|                       |          | on |   |    |   |       |              |
|                       |          | .* |   |    |   |       |              |
|                       |          |    |   |    |   |       |              |
|                       |          | *  |   |    |   |       |              |
|                       |          | Pl |   |    |   |       |              |
|                       |          | ea |   |    |   |       |              |
|                       |          | se |   |    |   |       |              |
|                       |          | c  |   |    |   |       |              |
|                       |          | he |   |    |   |       |              |
|                       |          | ck |   |    |   |       |              |
|                       |          | if |   |    |   |       |              |
|                       |          | y  |   |    |   |       |              |
|                       |          | es |   |    |   |       |              |
|                       |          | a  |   |    |   |       |              |
|                       |          | nd |   |    |   |       |              |
|                       |          | a  |   |    |   |       |              |
|                       |          | gr |   |    |   |       |              |
|                       |          | as |   |    |   |       |              |
|                       |          | sr |   |    |   |       |              |
|                       |          | oo |   |    |   |       |              |
|                       |          | ts |   |    |   |       |              |
|                       |          | or |   |    |   |       |              |
|                       |          | ga |   |    |   |       |              |
|                       |          | ni |   |    |   |       |              |
|                       |          | za |   |    |   |       |              |
|                       |          | ti |   |    |   |       |              |
|                       |          | on |   |    |   |       |              |
|                       |          | .* |   |    |   |       |              |
+-----------------------+----------+----+---+----+---+-------+--------------+

+-----------------------------------+-----------------------------------+
| *I hereby certify that all the    |                                   |
| information stated herein, as     |                                   |
| well as any information provided  |                                   |
| in the accompaniment herewith, is |                                   |
| true and accurate.***\            |                                   |
| Warning:** HUD will refer for     |                                   |
| prosecution 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 and Title of Authorized    | **Signature & Date (mm/dd/yy)**   |
| Official**                        |                                   |
|                                   |                                   |
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| **Name and Title of Contact at    | **Email Address**                 |
| Grantee Agency\                   |                                   |
| ***(person who can answer         |                                   |
| questions about the report and    |                                   |
| program)*                         |                                   |
|                                   |                                   |
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| **Phone Number (include area      | **Fax Number (include area        |
| code)**                           | code)**                           |
|                                   |                                   |
|                                   |                                   |
+-----------------------------------+-----------------------------------+

\* Service delivery area information only needed for program activities
being directly carried out by the grantee

**2.** **Subrecipient Information/Grantee Activities**

Provide the following information for [each]{.underline} organization
with a contract/agreement of \$25,000 or greater that assists grantee by
carrying out grantee functions such as evaluation or other
administrative services. Agreements include: grants, subgrants, loans,
awards, cooperative agreements, and other forms of financial assistance;
and contracts, subcontracts, purchase orders, task orders, and delivery
orders. These elements address requirements in the Federal Financial
Accountability and Transparency Act of 2006 (Public Law 109-282). *Note:
This chart does not apply to organizations designated or selected to
serve as project sponsors, defined by CFR 574.3, in providing housing
and other support to beneficiaries.* *Report the Project Sponsor
Information in Part 5, A: Summary of Project Sponsor Information.
Additionally, if the grantee undertakes service delivery activities
directly, complete the respective performance sections (Part 5B-5F) for
all activities conducted by the grantee.*

+----------------------+-----------------+---+---+---+------------+--------+
| **Organization**     |                 |   | * |   |            |        |
|                      |                 |   | * |   |            |        |
|                      |                 |   | P |   |            |        |
|                      |                 |   | a |   |            |        |
|                      |                 |   | r |   |            |        |
|                      |                 |   | e |   |            |        |
|                      |                 |   | n |   |            |        |
|                      |                 |   | t |   |            |        |
|                      |                 |   | C |   |            |        |
|                      |                 |   | o |   |            |        |
|                      |                 |   | m |   |            |        |
|                      |                 |   | p |   |            |        |
|                      |                 |   | a |   |            |        |
|                      |                 |   | n |   |            |        |
|                      |                 |   | y |   |            |        |
|                      |                 |   | ( |   |            |        |
|                      |                 |   | i |   |            |        |
|                      |                 |   | f |   |            |        |
|                      |                 |   | a |   |            |        |
|                      |                 |   | p |   |            |        |
|                      |                 |   | p |   |            |        |
|                      |                 |   | l |   |            |        |
|                      |                 |   | i |   |            |        |
|                      |                 |   | c |   |            |        |
|                      |                 |   | a |   |            |        |
|                      |                 |   | b |   |            |        |
|                      |                 |   | l |   |            |        |
|                      |                 |   | e |   |            |        |
|                      |                 |   | ) |   |            |        |
|                      |                 |   | * |   |            |        |
|                      |                 |   | * |   |            |        |
|                      |                 |   |   |   |            |        |
|                      |                 |   |   |   |            |        |
|                      |                 |   |   |   |            |        |
|                      |                 |   |   |   |            |        |
|                      |                 |   |   |   |            |        |
|                      |                 |   |   |   |            |        |
+----------------------+-----------------+---+---+---+------------+--------+
| **Name and Title of  |                 |   |   |   |            |        |
| Contact at           |                 |   |   |   |            |        |
| Subrecipient         |                 |   |   |   |            |        |
| Organization**       |                 |   |   |   |            |        |
+----------------------+-----------------+---+---+---+------------+--------+
| **Email Address**    |                 |   |   |   |            |        |
+----------------------+-----------------+---+---+---+------------+--------+
| **Business Address** |                 |   |   |   |            |        |
+----------------------+-----------------+---+---+---+------------+--------+
| **City, State, Zip,  |                 |   |   |   |            |        |
| County**             |                 |   |   |   |            |        |
|                      |                 |   |   |   |            |        |
|                      |                 |   |   |   |            |        |
|                      |                 |   |   |   |            |        |
+----------------------+-----------------+---+---+---+------------+--------+
| **Phone Number       |                 |   |   | * |            |        |
| (include area        |                 |   |   | * |            |        |
| code)**              |                 |   |   | F |            |        |
|                      |                 |   |   | a |            |        |
|                      |                 |   |   | x |            |        |
|                      |                 |   |   | N |            |        |
|                      |                 |   |   | u |            |        |
|                      |                 |   |   | m |            |        |
|                      |                 |   |   | b |            |        |
|                      |                 |   |   | e |            |        |
|                      |                 |   |   | r |            |        |
|                      |                 |   |   | ( |            |        |
|                      |                 |   |   | i |            |        |
|                      |                 |   |   | n |            |        |
|                      |                 |   |   | c |            |        |
|                      |                 |   |   | l |            |        |
|                      |                 |   |   | u |            |        |
|                      |                 |   |   | d |            |        |
|                      |                 |   |   | e |            |        |
|                      |                 |   |   | a |            |        |
|                      |                 |   |   | r |            |        |
|                      |                 |   |   | e |            |        |
|                      |                 |   |   | a |            |        |
|                      |                 |   |   | c |            |        |
|                      |                 |   |   | o |            |        |
|                      |                 |   |   | d |            |        |
|                      |                 |   |   | e |            |        |
|                      |                 |   |   | ) |            |        |
|                      |                 |   |   | * |            |        |
|                      |                 |   |   | * |            |        |
|                      |                 |   |   |   |            |        |
|                      |                 |   |   |   |            |        |
|                      |                 |   |   |   |            |        |
|                      |                 |   |   |   |            |        |
|                      |                 |   |   |   |            |        |
|                      |                 |   |   |   |            |        |
+----------------------+-----------------+---+---+---+------------+--------+
| **Employer           |                 |   | * |   |            |        |
| Identification       |                 |   | * |   |            |        |
| Number (EIN) or**    |                 |   | D |   |            |        |
|                      |                 |   | U |   |            |        |
| **Tax Identification |                 |   | N |   |            |        |
| Number (TIN)**       |                 |   | & |   |            |        |
|                      |                 |   | B |   |            |        |
|                      |                 |   | r |   |            |        |
|                      |                 |   | a |   |            |        |
|                      |                 |   | d |   |            |        |
|                      |                 |   | s |   |            |        |
|                      |                 |   | t |   |            |        |
|                      |                 |   | r |   |            |        |
|                      |                 |   | e |   |            |        |
|                      |                 |   | e |   |            |        |
|                      |                 |   | t |   |            |        |
|                      |                 |   | N |   |            |        |
|                      |                 |   | u |   |            |        |
|                      |                 |   | m |   |            |        |
|                      |                 |   | b |   |            |        |
|                      |                 |   | e |   |            |        |
|                      |                 |   | r |   |            |        |
|                      |                 |   | ( |   |            |        |
|                      |                 |   | D |   |            |        |
|                      |                 |   | U |   |            |        |
|                      |                 |   | N |   |            |        |
|                      |                 |   | s |   |            |        |
|                      |                 |   | ) |   |            |        |
|                      |                 |   | * |   |            |        |
|                      |                 |   | i |   |            |        |
|                      |                 |   | f |   |            |        |
|                      |                 |   | a |   |            |        |
|                      |                 |   | p |   |            |        |
|                      |                 |   | p |   |            |        |
|                      |                 |   | l |   |            |        |
|                      |                 |   | i |   |            |        |
|                      |                 |   | c |   |            |        |
|                      |                 |   | a |   |            |        |
|                      |                 |   | b |   |            |        |
|                      |                 |   | l |   |            |        |
|                      |                 |   | e |   |            |        |
|                      |                 |   | * |   |            |        |
|                      |                 |   | * |   |            |        |
|                      |                 |   | * |   |            |        |
|                      |                 |   |   |   |            |        |
|                      |                 |   |   |   |            |        |
|                      |                 |   |   |   |            |        |
|                      |                 |   |   |   |            |        |
|                      |                 |   |   |   |            |        |
|                      |                 |   |   |   |            |        |
+----------------------+-----------------+---+---+---+------------+--------+
| **North American     |                 |   |   |   |            |        |
| Industry             |                 |   |   |   |            |        |
| Classification       |                 |   |   |   |            |        |
| System (NAICS)       |                 |   |   |   |            |        |
| Code**               |                 |   |   |   |            |        |
+----------------------+-----------------+---+---+---+------------+--------+
| **Congressional      |                 |   |   |   |            |        |
| District of          |                 |   |   |   |            |        |
| Location**           |                 |   |   |   |            |        |
+----------------------+-----------------+---+---+---+------------+--------+
| **Congressional      |                 |   |   |   |            |        |
| District of Primary  |                 |   |   |   |            |        |
| Service Area**       |                 |   |   |   |            |        |
+----------------------+-----------------+---+---+---+------------+--------+
| **Zip Code of        |                 |   |   |   |            |        |
| Primary Service      |                 |   |   |   |            |        |
| Area(s)**            |                 |   |   |   |            |        |
+----------------------+-----------------+---+---+---+------------+--------+
| **City(ies) and      |                 |   |   |   |            |        |
| County(ies) of       |                 |   |   |   |            |        |
| Primary Service      |                 |   |   |   |            |        |
| Area(s)**            |                 |   |   |   |            |        |
+----------------------+-----------------+---+---+---+------------+--------+
| **Total HOPWA        |                 |   |   |   |            |        |
| Contract Amount**    |                 |   |   |   |            |        |
+----------------------+-----------------+---+---+---+------------+--------+
|                      |                 |   |   |   |            |        |
+----------------------+-----------------+---+---+---+------------+--------+

**Part 2: Grantee Narrative and Performance Assessment**

[]{.mark}

Address items A through D in a one to three page narrative that
succinctly assesses how activities undertaken during the operating year
met HOPWA program goals and accomplishments, enabled client households
to improve housing stability, increased access to care and support, and
reduced their risk of homelessness. Describe any innovative outreach and
support provided by project sponsor or partner organizations to the
target population. In addition, provide information on any evaluations
of the project's accomplishments conducted during the operating year.
This narrative will be used for public information, including posting on
HUD's web page.

**A. Outputs Reported.** Describe program accomplishments including the
number of housing units supported and the number households assisted
with HOPWA funds during this operating year. [Include a comparison
between proposed (as approved in the grant agreement) and actual
accomplishments,]{.underline} as demonstrated in Part 3: Overview of
Grant Activities. In the narrative, describe how housing assistance is
coordinated to serve clients. If your organization has a waiting list,
please explain how it is administered.

     

**B. Outcomes Assessed.** Assess your program's success in enabling
HOPWA beneficiaries to establish and/or better maintain a stable living
environment in housing that is safe, decent, and sanitary, and improve
access to care. Compare current year results to baseline results for
clients. Describe how program activities/projects contributed to meeting
stated goals. If current year results are lower than the national
program targets (80 percent of HOPWA clients will maintain housing
stability, avoid homelessness and access care each year), please
explain. Please describe how your program plans to address challenges in
program implementation and the steps currently being taken to achieve
goals in next operating year.

     

**C. Barriers and Recommendations.** Describe any barriers (including
regulatory and non-regulatory) encountered, how they affected your
program's ability to achieve the objectives and outcomes discussed, and
actions taken in response to barriers, as well as recommendations for
program improvement. You may select more than one from the following
list. [Specify a barrier for each explanation or
description]{.underline}.

+-----------------------------------------------------------------------+
| HOPWA/HUD Regulations Planning Housing Availability Rent              |
| Determination and Fair Market Rents Discrimination/Confidentiality    |
| Multiple Diagnoses Eligibility Technical Assistance or Training       |
|                                                                       |
| Supportive Services Credit History Rental History Criminal Justice    |
| History                                                               |
|                                                                       |
| Housing Affordability Other, please explain further                   |
+-----------------------------------------------------------------------+

     

**D. Technical Assistance.** Describe any technical assistance needs and
how they will benefit program beneficiaries.

     

[]{.mark}

**E. Logic Model.** Attach a copy of your grant's updated Logic Model on
your annual accomplishments under the HOPWA performance goals and the
optional goals you established in your grant application. *\*Reference
(data requested consistent with Form HUD-96010 Program Outcome Logic
Model)*

[]{.mark}

[]{.mark}

[]{.mark}

**F. Unmet Housing Need: Assessment of Unmet Housing Needs for HOPWA
eligible Households.**

In Chart 1, please identify your service area. If your service area
operates within an area also served by formula funds, check line a. If
you are the single HOPWA service provider in your area, check line b. In
Chart 2 item 1, provide an assessment of the total number HOPWA-eligible
households that require housing assistance, but are not served by HOPWA
in this service area. In Rows a through c, enter the total number of
HOPWA-eligible households by type of housing assistance whose housing
needs remain unmet. Do not include clients who are already receiving
HOPWA assistance.

Refer to Chart 3, and check all sources consulted to calculate unmet
need. Reference any data from neighboring states' or municipalities'
Consolidated Plan or other planning efforts that informed the assessment
of Unmet Need in your service area.

1\. Service Area:

+--------------------------------------------------+-------------------+
| a.  Program operates within an area also served  |                   |
|     with HOPWA formula funds \[Unmet Needs       |                   |
|     Assessment is optional for this group of     |                   |
|     competitive grantees\]                       |                   |
+--------------------------------------------------+-------------------+
| b.  Program operates in an area that is not      |                   |
|     eligible for HOPWA formula funds             |                   |
+--------------------------------------------------+-------------------+

2\. Assessment of Area's Unmet Needs for HOPWA-eligible Households

+---------------------------------+------------------------------------+
| 1\. Total number of households  | =                                  |
| that have unmet housing needs   |                                    |
+---------------------------------+------------------------------------+
| ### **From Item 1               |                                    |
| , identify the number of househ |                                    |
| olds with unmet housing needs b |                                    |
| y type of housing assistance.** |                                    |
+---------------------------------+------------------------------------+
| a\. Tenant-Based Rental         | =                                  |
| Assistance (TBRA)               |                                    |
+---------------------------------+------------------------------------+
| b\. Short-Term Rent, Mortgage   | =                                  |
| and Utility payments (STRMU)    |                                    |
+---------------------------------+------------------------------------+
| c\. Housing Facilities, such as | =                                  |
| community residences, SRO       |                                    |
|                                 |                                    |
| > dwellings, other housing      |                                    |
| > facilities                    |                                    |
+---------------------------------+------------------------------------+

#### **3. Recommended Data Sources for Assessing Unmet Need (check all sources used)**

  -----------------------------------------------------------------------
  **     ** **=** Data as reported in the area Consolidated Plan, e.g. in
  Table 1B, CPMP charts, and related narratives

        = Data established by area HIV/AIDS housing planning and
  coordination efforts, e.g. Continuum of Care

        = Data from client information provided in Homeless Management
  Information Systems (HMIS)

        = Data from project sponsors or housing providers, including
  waiting lists for assistance or other assessments on needs

        = Data from prisons or jails in the community on persons being
  discharged with HIV/AIDS, if mandatory testing is conducted

        = Data from local Ryan White Planning Councils or reported in
  CARE Act Data Reports, e.g. number of clients with permanent housing

        = Data collected for HIV/AIDS surveillance reporting or related
  care assessments, e.g. local health department or CDC surveillance data
  -----------------------------------------------------------------------

**.**

**Part 3: Summary Overview of Grant Activities**

**A. Information on Individuals, Beneficiaries, and Households Receiving
HOPWA Housing Assistance**

> **Section 1. Individuals**
>
> Provide the total number of eligible (and unduplicated) [low income
> individuals living with HIV/AIDS]{.underline} who received HOPWA
> housing assistance during the operating year in Chart a. In Chart b,
> indicate the number of these eligible individuals with special needs:
> veterans; chronically homeless; and domestic violence survivor(s). In
> Chart c, report the prior living situations for all HOPWA eligible
> individuals that received HOPWA housing assistance in Chart a.

**a. Total HOPWA eligible individuals living with HIV/AIDS**

  --------------------------------------------------- -------------------
  **Individuals Served with Housing Assistance**      **Total Number**

  Number of individuals with HIV/AIDS who received    
  HOPWA housing assistance                            
  --------------------------------------------------- -------------------

**b. Special Needs.** *Note: The total of HOPWA eligible individuals
with special needs may not equal the total number of individuals served
with HOPWA housing assistance from Chart a, above.*

  -------------------- ---------------- ---------------- -----------------
  **Category**         **Veteran(s)**   **Chronically    **Domestic
                                        Homeless**       Violence
                                                         Survivor(s)**

  **TOTAL HOPWA                                          
  eligible individuals                                   
  served with Housing                                    
  Assistance**                                           
  -------------------- ---------------- ---------------- -----------------

**c. Prior Living Situation.**

Indicate the prior living arrangements for all eligible individuals who
received HOPWA housing assistance, reported in Chart a. In row 1,
identify the total number of individuals who will continue to receive
HOPWA housing support from the prior operating year. In rows 2 through
16, indicate the respective prior living arrangements for all new HOPWA
eligible individuals who received HOPWA housing assistance during the
operating year. *Note: The total number of eligible individuals served
in Row 17 should equal the total number of individuals served through
housing assistance reported in Chart a above.*

+---+--------------------------------------------------+---------------+
| * |                                                  | **Total HOPWA |
| * |                                                  | Eligible      |
| C |                                                  | Individuals   |
| a |                                                  | Served with   |
| t |                                                  | Housing       |
| e |                                                  | Assistance**  |
| g |                                                  |               |
| o |                                                  |               |
| r |                                                  |               |
| y |                                                  |               |
| * |                                                  |               |
| * |                                                  |               |
+---+--------------------------------------------------+---------------+
| 1 | [Continuing]{.underline} to receive HOPWA        |               |
| \ | support from the prior operating year            |               |
| . |                                                  |               |
+---+--------------------------------------------------+---------------+
| * |                                                  |               |
| * |                                                  |               |
| N |                                                  |               |
| e |                                                  |               |
| w |                                                  |               |
| I |                                                  |               |
| n |                                                  |               |
| d |                                                  |               |
| i |                                                  |               |
| v |                                                  |               |
| i |                                                  |               |
| d |                                                  |               |
| u |                                                  |               |
| a |                                                  |               |
| l |                                                  |               |
| s |                                                  |               |
| w |                                                  |               |
| h |                                                  |               |
| o |                                                  |               |
| r |                                                  |               |
| e |                                                  |               |
| c |                                                  |               |
| e |                                                  |               |
| i |                                                  |               |
| v |                                                  |               |
| e |                                                  |               |
| d |                                                  |               |
| H |                                                  |               |
| O |                                                  |               |
| P |                                                  |               |
| W |                                                  |               |
| A |                                                  |               |
| H |                                                  |               |
| o |                                                  |               |
| u |                                                  |               |
| s |                                                  |               |
| i |                                                  |               |
| n |                                                  |               |
| g |                                                  |               |
| A |                                                  |               |
| s |                                                  |               |
| s |                                                  |               |
| i |                                                  |               |
| s |                                                  |               |
| t |                                                  |               |
| a |                                                  |               |
| n |                                                  |               |
| c |                                                  |               |
| e |                                                  |               |
| s |                                                  |               |
| u |                                                  |               |
| p |                                                  |               |
| p |                                                  |               |
| o |                                                  |               |
| r |                                                  |               |
| t |                                                  |               |
| d |                                                  |               |
| u |                                                  |               |
| r |                                                  |               |
| i |                                                  |               |
| n |                                                  |               |
| g |                                                  |               |
| O |                                                  |               |
| p |                                                  |               |
| e |                                                  |               |
| r |                                                  |               |
| a |                                                  |               |
| t |                                                  |               |
| i |                                                  |               |
| n |                                                  |               |
| g |                                                  |               |
| Y |                                                  |               |
| e |                                                  |               |
| a |                                                  |               |
| r |                                                  |               |
| * |                                                  |               |
| * |                                                  |               |
+---+--------------------------------------------------+---------------+
| 2 | Place not meant for human habitation             |               |
| \ |                                                  |               |
| . | (such as a vehicle, abandoned building,          |               |
|   | bus/train/subway station/airport, or outside)    |               |
+---+--------------------------------------------------+---------------+
| 3 | Emergency shelter (including hotel, motel, or    |               |
| \ | campground paid for with emergency shelter       |               |
| . | voucher)                                         |               |
+---+--------------------------------------------------+---------------+
| 4 | Transitional housing for homeless persons        |               |
| \ |                                                  |               |
| . |                                                  |               |
+---+--------------------------------------------------+---------------+
| 5 | Permanent housing for formerly homeless persons  |               |
| \ | (such as Shelter Plus Care, SHP, or SRO Mod      |               |
| . | Rehab)                                           |               |
+---+--------------------------------------------------+---------------+
| 6 | Psychiatric hospital or other psychiatric        |               |
| \ | facility                                         |               |
| . |                                                  |               |
+---+--------------------------------------------------+---------------+
| 7 | Substance abuse treatment facility or detox      |               |
| \ | center                                           |               |
| . |                                                  |               |
+---+--------------------------------------------------+---------------+
| 8 | Hospital (non-psychiatric facility)              |               |
| \ |                                                  |               |
| . |                                                  |               |
+---+--------------------------------------------------+---------------+
| 9 | Foster care home or foster care group home       |               |
| \ |                                                  |               |
| . |                                                  |               |
+---+--------------------------------------------------+---------------+
| 1 | Jail, prison or juvenile detention facility      |               |
| 0 |                                                  |               |
| \ |                                                  |               |
| . |                                                  |               |
+---+--------------------------------------------------+---------------+
| 1 | Rented room, apartment, or house                 |               |
| 1 |                                                  |               |
| \ |                                                  |               |
| . |                                                  |               |
+---+--------------------------------------------------+---------------+
| 1 | House you own                                    |               |
| 2 |                                                  |               |
| \ |                                                  |               |
| . |                                                  |               |
+---+--------------------------------------------------+---------------+
| 1 | Staying or living in someone else's (family and  |               |
| 3 | friends) room, apartment, or house               |               |
| \ |                                                  |               |
| . |                                                  |               |
+---+--------------------------------------------------+---------------+
| 1 | Hotel or motel paid for without emergency        |               |
| 4 | shelter voucher                                  |               |
| \ |                                                  |               |
| . |                                                  |               |
+---+--------------------------------------------------+---------------+
| 1 | Other                                            |               |
| 5 |                                                  |               |
| \ |                                                  |               |
| . |                                                  |               |
+---+--------------------------------------------------+---------------+
| 1 | Don't Know or Refused                            |               |
| 6 |                                                  |               |
| \ |                                                  |               |
| . |                                                  |               |
+---+--------------------------------------------------+---------------+
| * | **TOTAL (sum of items 1-16)**                    |               |
| * |                                                  |               |
| 1 |                                                  |               |
| 7 |                                                  |               |
| . |                                                  |               |
| * |                                                  |               |
| * |                                                  |               |
+---+--------------------------------------------------+---------------+

**Section 2. Beneficiaries**

**HOPWA Beneficiaries.** In Chart a, report the total number of HOPWA
eligible individuals living with HIV/AIDS and all associated members of
their household who received HOPWA housing assistance (resided with
HOPWA eligible individuals living with HIV/AIDS). In Charts b and c,
indicate the age, gender, race and ethnicity for all beneficiaries
reported in Chart a. *Note: The sum of [each]{.underline} of the
following charts should equal the total number of beneficiaries served
with HOPWA housing assistance, in Chart a, Row 3.*

**a. Total Number of HOPWA Beneficiaries Served with Housing
Assistance**

  ---------------------------------------------------- ------------------
  **Individuals and Families Served with Housing       **Total Number**
  Assistance**                                         

  1\. Number of individuals with HIV/AIDS who received 
  HOPWA housing assistance (Chart a page 5)            

  2\. Number of other persons residing with the above  
  eligible individuals in HOPWA-assisted housing       

  **3.** **TOTAL number of [beneficiaries]{.underline} 
  served with Housing Assistance (Rows 1 + 2)**        
  ---------------------------------------------------- ------------------

**b. Age and Gender**

  -------------- --------------------- -------------------- ----------------------
  **Category**                         **Male**             **Female**

  1\.            Under 18                                   

  2\.            18 to 30 years                             

  3\.            31 to 50 years                             

  4\.            51 years and Older                         
  -------------- --------------------- -------------------- ----------------------

**c. Race and Ethnicity\***

+---+-----------+--------+---------+---+-----------+--------+---------+
|   | #         | *      | **Total |   | **C       | *      | **Total |
|   |           | *Total | Benefi  |   | ategory** | *Total | Benefi  |
|   | #         | B      | ciaries |   |           | B      | ciaries |
|   |           | enefic | also    |   |           | enefic | also    |
|   | # **C     | iaries | ide     |   |           | iaries | ide     |
|   | ategory** | Served | ntified |   |           | Served | ntified |
|   |           | with   | as      |   |           | with   | as      |
|   |           | H      | H       |   |           | H      | H       |
|   |           | ousing | ispanic |   |           | ousing | ispanic |
|   |           | Assist | or      |   |           | Assist | or      |
|   |           | ance** | L       |   |           | ance** | L       |
|   |           |        | atino** |   |           |        | atino** |
+---+-----------+--------+---------+---+-----------+--------+---------+
| 1 | American  |        |         | 6 | American  |        |         |
| \ | Indian/   |        |         | \ | Indian/   |        |         |
| . |           |        |         | . |           |        |         |
|   | Alaskan   |        |         |   | Alaskan   |        |         |
|   | Native    |        |         |   | Native &  |        |         |
|   |           |        |         |   | White     |        |         |
+---+-----------+--------+---------+---+-----------+--------+---------+
| 2 | Asian     |        |         | 7 | Asian &   |        |         |
| \ |           |        |         | \ | White     |        |         |
| . |           |        |         | . |           |        |         |
+---+-----------+--------+---------+---+-----------+--------+---------+
| 3 | Blac      |        |         | 8 | Blac      |        |         |
| \ | k/African |        |         | \ | k/African |        |         |
| . | American  |        |         | . | American  |        |         |
|   |           |        |         |   |           |        |         |
|   |           |        |         |   | and White |        |         |
+---+-----------+--------+---------+---+-----------+--------+---------+
| 4 | Native    |        |         | 9 | American  |        |         |
| \ | Hawai     |        |         | \ | Indian/   |        |         |
| . | ian/Other |        |         | . |           |        |         |
|   | Pacific   |        |         |   | Alaskan   |        |         |
|   | Islander  |        |         |   | Native &  |        |         |
|   |           |        |         |   | Blac      |        |         |
|   |           |        |         |   | k/African |        |         |
|   |           |        |         |   | American  |        |         |
+---+-----------+--------+---------+---+-----------+--------+---------+
| 5 | White     |        |         | 1 | Other     |        |         |
| \ |           |        |         | 0 | Mul       |        |         |
| . |           |        |         | \ | ti-Racial |        |         |
|   |           |        |         | . |           |        |         |
+---+-----------+--------+---------+---+-----------+--------+---------+

*\*Reference (data requested consistent with Form HUD-27061Race and
Ethnic Data Reporting Form)*

**Section 3. Households**

**Household Area Median Income.** Report the area median income(s) for
all households served with HOPWA housing assistance. The total number of
households served with housing assistance should equal Part 3C, Row 5.
*Note: Refer to [www.hud.gov](http://www.hud.gov/) for information on
area median income in your community.*

+---+------------------------------------------------+----------------+
| # |                                                | **Households   |
|   |                                                | Served with    |
| * |                                                | Housing        |
| * |                                                | Assistance**   |
| P |                                                |                |
| e |                                                |                |
| r |                                                |                |
| c |                                                |                |
| e |                                                |                |
| n |                                                |                |
| t |                                                |                |
| a |                                                |                |
| g |                                                |                |
| e |                                                |                |
|   |                                                |                |
| o |                                                |                |
| f |                                                |                |
|   |                                                |                |
| A |                                                |                |
| r |                                                |                |
| e |                                                |                |
| a |                                                |                |
|   |                                                |                |
| M |                                                |                |
| e |                                                |                |
| d |                                                |                |
| i |                                                |                |
| a |                                                |                |
| n |                                                |                |
|   |                                                |                |
| I |                                                |                |
| n |                                                |                |
| c |                                                |                |
| o |                                                |                |
| m |                                                |                |
| e |                                                |                |
| * |                                                |                |
| * |                                                |                |
+---+------------------------------------------------+----------------+
| 1 | 0-30% of area median income (extremely low)    |                |
| \ |                                                |                |
| . |                                                |                |
+---+------------------------------------------------+----------------+
| 2 | 31-50% of area median income (very low)        |                |
| \ |                                                |                |
| . |                                                |                |
+---+------------------------------------------------+----------------+
| 3 | 51-60% of area median income (low)             |                |
| \ |                                                |                |
| . |                                                |                |
+---+------------------------------------------------+----------------+
| 4 | 61-80% of area median income (low)             |                |
| \ |                                                |                |
| . |                                                |                |
+---+------------------------------------------------+----------------+

**Part 3: Summary Overview of Grant Activities**

**B. Budget and Grant Sources for Leveraging**

In Chart 1, indicate the total number of HOPWA eligible households
assisted with leveraging funds. In Chart 2, identify the type and
source(s) of cash or in-kind leveraged federal, state, local or private
resources used in the delivery of the HOPWA program, amount. *Note:
Leveraged funds include non-HOPWA funds used for on-site or other
specific activities directly connected to serving HOPWA client
households, at the activity or program level. Competitive grantees
should report leveraged resources consistent with leveraging approved in
their Grant Application. Formula grantees should report leveraged
resources identified in their most recent Consolidated Plan or Annual
Plan.*

**1. Households Assisted with Leveraged Funds for Housing**

+----------+---------+----------+-----------+-----------+------------+
| **\[A\]  | **\[1\] | **\[2\]  | **\[3\]   | **\[4\]   | **\[5\]    |
| Housing  | Tenan   | P        | Transi    | S         | Number of  |
| Assi     | t-Based | ermanent | tional/** | hort-Term | Units in   |
| stance** | Rental  | Housing  |           | A         | Facilities |
|          | Ass     | Faci     | **S       | ssistance | under      |
| **O      | istance | lities** | hort-term | (STRMU)** | Dev        |
| utputs** | (       |          | Housing   |           | elopment** |
|          | TBRA)** |          | Fac       |           |            |
|          |         |          | ilities** |           |            |
+----------+---------+----------+-----------+-----------+------------+
| 1\.      |         |          |           |           |            |
| Total    |         |          |           |           |            |
| Ho       |         |          |           |           |            |
| useholds |         |          |           |           |            |
| Assisted |         |          |           |           |            |
+----------+---------+----------+-----------+-----------+------------+
| 2\.      |         |          |           |           |            |
| Total    |         |          |           |           |            |
| Units    |         |          |           |           |            |
+----------+---------+----------+-----------+-----------+------------+

Note: Please report households receiving leveraged funds only, exclusive
of the HOPWA funding.

**2. Sources of Leveraged Funds and Amount Used for Housing Assistance
and Supportive Services**

+---+----------------------------+-------------------+------------------+
| * |                            | **Total Amount of |                  |
| * |                            | Leveraged Dollars |                  |
| \ |                            | (for this         |                  |
| [ |                            | operating year)** |                  |
| 1 |                            |                   |                  |
| \ |                            | **as approved in  |                  |
| ] |                            | grant             |                  |
| S |                            | application**     |                  |
| o |                            |                   |                  |
| u |                            |                   |                  |
| r |                            |                   |                  |
| c |                            |                   |                  |
| e |                            |                   |                  |
| s |                            |                   |                  |
| o |                            |                   |                  |
| f |                            |                   |                  |
| L |                            |                   |                  |
| e |                            |                   |                  |
| v |                            |                   |                  |
| e |                            |                   |                  |
| r |                            |                   |                  |
| a |                            |                   |                  |
| g |                            |                   |                  |
| i |                            |                   |                  |
| n |                            |                   |                  |
| g |                            |                   |                  |
| * |                            |                   |                  |
| * |                            |                   |                  |
+---+----------------------------+-------------------+------------------+
|   |                            | **\[2\] Housing   | **\[3\]          |
|   |                            | Assistance**      | Supportive       |
|   |                            |                   | Services and     |
|   |                            |                   | other non-direct |
|   |                            |                   | housing costs**  |
+---+----------------------------+-------------------+------------------+
| 1 | Program income             | =                 | =                |
| \ |                            |                   |                  |
| . |                            |                   |                  |
+---+----------------------------+-------------------+------------------+
| 2 | Federal government (please | =                 | =                |
| \ | specify):                  |                   |                  |
| . |                            |                   |                  |
+---+----------------------------+-------------------+------------------+
|   |                            | =                 | =                |
+---+----------------------------+-------------------+------------------+
|   |                            | =                 | =                |
+---+----------------------------+-------------------+------------------+
|   |                            | =                 | =                |
+---+----------------------------+-------------------+------------------+
| 3 | State government (please   | =                 | =                |
| \ | specify)                   |                   |                  |
| . |                            |                   |                  |
+---+----------------------------+-------------------+------------------+
|   |                            | =                 | =                |
+---+----------------------------+-------------------+------------------+
|   |                            | =                 | =                |
+---+----------------------------+-------------------+------------------+
|   |                            | =                 | =                |
+---+----------------------------+-------------------+------------------+
| 4 | Local government (please   | =                 | =                |
| \ | specify)                   |                   |                  |
| . |                            |                   |                  |
+---+----------------------------+-------------------+------------------+
|   |                            | =                 | =                |
+---+----------------------------+-------------------+------------------+
|   |                            | =                 | =                |
+---+----------------------------+-------------------+------------------+
|   |                            | =                 | =                |
+---+----------------------------+-------------------+------------------+
| 5 | Foundations and other      | =                 | =                |
| \ | private cash resources     |                   |                  |
| . | (please specify)           |                   |                  |
+---+----------------------------+-------------------+------------------+
|   |                            | =                 | =                |
+---+----------------------------+-------------------+------------------+
|   |                            | =                 | =                |
+---+----------------------------+-------------------+------------------+
|   |                            | =                 | =                |
+---+----------------------------+-------------------+------------------+
| 6 | In-kind Resources          | =                 | =                |
| \ |                            |                   |                  |
| . |                            |                   |                  |
+---+----------------------------+-------------------+------------------+
| 7 | Resident rent payments in  | =                 | =                |
| \ | Rental, Project-Based      |                   |                  |
| . | Units, and Facilities      |                   |                  |
+---+----------------------------+-------------------+------------------+
| 8 | Grantee/project sponsor    | =                 | =                |
| \ | (Agency) cash              |                   |                  |
| . |                            |                   |                  |
+---+----------------------------+-------------------+------------------+
| 9 | **TOTAL (Sum of 1-7)**     | =                 | =                |
| \ |                            |                   |                  |
| . |                            |                   |                  |
+---+----------------------------+-------------------+------------------+
|   |                            |                   |                  |
+---+----------------------------+-------------------+------------------+

**Part 3: Summary Overview of Grant Activities**

**C. Performance and Expenditure Information**

Report the total number of households that received HOPWA assistance and
the amount of HOPWA funds expended for all grant activities. The total
for each activity type represents an [unduplicated]{.underline} number
of households/units assisted during the operating year (the annual
output measures for HOPWA program). *Note: Data in this section is
summarized from all project sponsors PART 5 submissions. All HOPWA
housing assistance activities are measured in households served, and
housing development activities are measured in units developed.*

**[1. Performance and Expenditure Information by Activity
Type]{.underline}**

+---+--------------------+---------------------+----------------------+
| * |                    | **\[1\] HOPWA       | **\[2\] Amount of    |
| * |                    | Assistance Outputs: | HOPWA Funds          |
| H |                    | Households**        | Expended**           |
| o |                    |                     |                      |
| u |                    |                     |                      |
| s |                    |                     |                      |
| i |                    |                     |                      |
| n |                    |                     |                      |
| g |                    |                     |                      |
| S |                    |                     |                      |
| u |                    |                     |                      |
| b |                    |                     |                      |
| s |                    |                     |                      |
| i |                    |                     |                      |
| d |                    |                     |                      |
| y |                    |                     |                      |
| A |                    |                     |                      |
| s |                    |                     |                      |
| s |                    |                     |                      |
| i |                    |                     |                      |
| s |                    |                     |                      |
| t |                    |                     |                      |
| a |                    |                     |                      |
| n |                    |                     |                      |
| c |                    |                     |                      |
| e |                    |                     |                      |
| * |                    |                     |                      |
| * |                    |                     |                      |
+---+--------------------+---------------------+----------------------+
| 1 | Tenant-Based       |                     |                      |
| \ | Rental Assistance  |                     |                      |
| . |                    |                     |                      |
+---+--------------------+---------------------+----------------------+
| 2 | Households in      |                     |                      |
| a | permanent housing  |                     |                      |
| . | facilities that    |                     |                      |
|   | receive operating  |                     |                      |
|   | subsidies/leased   |                     |                      |
|   | units              |                     |                      |
+---+--------------------+---------------------+----------------------+
| 2 | Households in      |                     |                      |
| b | trans              |                     |                      |
| . | itional/short-term |                     |                      |
|   | facilities that    |                     |                      |
|   | receive operating  |                     |                      |
|   | subsidies          |                     |                      |
+---+--------------------+---------------------+----------------------+
| 3 | Households in      |                     |                      |
| a | permanent housing  |                     |                      |
| . | facilities         |                     |                      |
|   | developed with     |                     |                      |
|   | capital funds, and |                     |                      |
|   | placed in service  |                     |                      |
|   | during the         |                     |                      |
|   | operating year     |                     |                      |
+---+--------------------+---------------------+----------------------+
| 3 | Households in      |                     |                      |
| b | trans              |                     |                      |
| . | itional/short-term |                     |                      |
|   | facilities         |                     |                      |
|   | developed with     |                     |                      |
|   | capital funds, and |                     |                      |
|   | placed in service  |                     |                      |
|   | during the         |                     |                      |
|   | operating year     |                     |                      |
+---+--------------------+---------------------+----------------------+
| 4 | Short-term Rent,   |                     |                      |
| \ | Mortgage, and      |                     |                      |
| . | Utility Assistance |                     |                      |
+---+--------------------+---------------------+----------------------+
| 5 | Adjustment for     |                     | []{.mark}            |
| \ | duplication        |                     |                      |
| . | (subtract)         |                     |                      |
+---+--------------------+---------------------+----------------------+
| * | **TOTAL Housing    |                     |                      |
| * | Assistance**       |                     |                      |
| 6 |                    |                     |                      |
| . |                    |                     |                      |
| * |                    |                     |                      |
| * |                    |                     |                      |
+---+--------------------+---------------------+----------------------+
| [ |                    |                     |                      |
| ] |                    |                     |                      |
| { |                    |                     |                      |
| . |                    |                     |                      |
| m |                    |                     |                      |
| a |                    |                     |                      |
| r |                    |                     |                      |
| k |                    |                     |                      |
| } |                    |                     |                      |
+---+--------------------+---------------------+----------------------+
| * |                    | **\[1\] HOPWA       | **\[2\] Amount of    |
| * |                    | Assistance Outputs: | HOPWA Funds          |
| H |                    | Units**             | Expended**           |
| o |                    |                     |                      |
| u |                    |                     |                      |
| s |                    |                     |                      |
| i |                    |                     |                      |
| n |                    |                     |                      |
| g |                    |                     |                      |
| D |                    |                     |                      |
| e |                    |                     |                      |
| v |                    |                     |                      |
| e |                    |                     |                      |
| l |                    |                     |                      |
| o |                    |                     |                      |
| p |                    |                     |                      |
| m |                    |                     |                      |
| e |                    |                     |                      |
| n |                    |                     |                      |
| t |                    |                     |                      |
| * |                    |                     |                      |
| * |                    |                     |                      |
|   |                    |                     |                      |
| * |                    |                     |                      |
| * |                    |                     |                      |
| ( |                    |                     |                      |
| C |                    |                     |                      |
| o |                    |                     |                      |
| n |                    |                     |                      |
| s |                    |                     |                      |
| t |                    |                     |                      |
| r |                    |                     |                      |
| u |                    |                     |                      |
| c |                    |                     |                      |
| t |                    |                     |                      |
| i |                    |                     |                      |
| o |                    |                     |                      |
| n |                    |                     |                      |
| a |                    |                     |                      |
| n |                    |                     |                      |
| d |                    |                     |                      |
| S |                    |                     |                      |
| t |                    |                     |                      |
| e |                    |                     |                      |
| w |                    |                     |                      |
| a |                    |                     |                      |
| r |                    |                     |                      |
| d |                    |                     |                      |
| s |                    |                     |                      |
| h |                    |                     |                      |
| i |                    |                     |                      |
| p |                    |                     |                      |
| o |                    |                     |                      |
| f |                    |                     |                      |
| F |                    |                     |                      |
| a |                    |                     |                      |
| c |                    |                     |                      |
| i |                    |                     |                      |
| l |                    |                     |                      |
| i |                    |                     |                      |
| t |                    |                     |                      |
| y |                    |                     |                      |
| - |                    |                     |                      |
| B |                    |                     |                      |
| a |                    |                     |                      |
| s |                    |                     |                      |
| e |                    |                     |                      |
| d |                    |                     |                      |
| H |                    |                     |                      |
| o |                    |                     |                      |
| u |                    |                     |                      |
| s |                    |                     |                      |
| i |                    |                     |                      |
| n |                    |                     |                      |
| g |                    |                     |                      |
| ) |                    |                     |                      |
| * |                    |                     |                      |
| * |                    |                     |                      |
+---+--------------------+---------------------+----------------------+
| 7 | Facility-Based     |                     |                      |
| \ | units being        |                     |                      |
| . | developed with     |                     |                      |
|   | capital funding    |                     |                      |
|   | but not yet opened |                     |                      |
|   | (identify units of |                     |                      |
|   | housing planned)   |                     |                      |
+---+--------------------+---------------------+----------------------+
| 8 | Stewardship units  |                     | []{.mark}            |
| \ | subject to 3- or   |                     |                      |
| . | 10- year use       |                     |                      |
|   | periods            |                     |                      |
+---+--------------------+---------------------+----------------------+
| * | **TOTAL Housing    |                     |                      |
| * | Development**      |                     |                      |
| 9 |                    |                     |                      |
| . |                    |                     |                      |
| * |                    |                     |                      |
| * |                    |                     |                      |
+---+--------------------+---------------------+----------------------+
|   |                    |                     |                      |
+---+--------------------+---------------------+----------------------+

+---+--------------------+---------------------+----------------------+
| * |                    | **\[1\] HOPWA       | **\[2\] Amount of    |
| * |                    | Assistance Outputs: | HOPWA Funds          |
| S |                    | Households**        | Expended**           |
| u |                    |                     |                      |
| p |                    |                     |                      |
| p |                    |                     |                      |
| o |                    |                     |                      |
| r |                    |                     |                      |
| t |                    |                     |                      |
| i |                    |                     |                      |
| v |                    |                     |                      |
| e |                    |                     |                      |
| S |                    |                     |                      |
| e |                    |                     |                      |
| r |                    |                     |                      |
| v |                    |                     |                      |
| i |                    |                     |                      |
| c |                    |                     |                      |
| e |                    |                     |                      |
| s |                    |                     |                      |
| * |                    |                     |                      |
| * |                    |                     |                      |
+---+--------------------+---------------------+----------------------+
| 1 | Supportive         |                     |                      |
| 0 | Services provided  |                     |                      |
| a | by project         |                     |                      |
| . | sponsors also      |                     |                      |
|   | delivering HOPWA   |                     |                      |
|   | housing assistance |                     |                      |
|   | (as reported in    |                     |                      |
|   | Part 5 D, 1a)      |                     |                      |
+---+--------------------+---------------------+----------------------+
| 1 | Supportive         |                     |                      |
| 0 | Services provided  |                     |                      |
| b | by project         |                     |                      |
| . | sponsors serving   |                     |                      |
|   | households who     |                     |                      |
|   | have other housing |                     |                      |
|   | arrangements       |                     |                      |
|   |                    |                     |                      |
|   | (as reported in    |                     |                      |
|   | Part 5, D, 1b)     |                     |                      |
+---+--------------------+---------------------+----------------------+
| 1 | Adjustment for     |                     |                      |
| 1 | duplication        |                     |                      |
| \ | (subtract)         |                     |                      |
| . |                    |                     |                      |
+---+--------------------+---------------------+----------------------+
| 1 | **TOTAL Supportive |                     |                      |
| 2 | Services**         |                     |                      |
| \ |                    |                     |                      |
| . |                    |                     |                      |
+---+--------------------+---------------------+----------------------+
|   |                    |                     |                      |
+---+--------------------+---------------------+----------------------+
| * |                    | **\[1\] HOPWA       | **\[2\] Amount of    |
| * |                    | Assistance Outputs: | HOPWA Funds          |
| H |                    | Households**        | Expended**           |
| o |                    |                     |                      |
| u |                    |                     |                      |
| s |                    |                     |                      |
| i |                    |                     |                      |
| n |                    |                     |                      |
| g |                    |                     |                      |
| P |                    |                     |                      |
| l |                    |                     |                      |
| a |                    |                     |                      |
| c |                    |                     |                      |
| e |                    |                     |                      |
| m |                    |                     |                      |
| e |                    |                     |                      |
| n |                    |                     |                      |
| t |                    |                     |                      |
| A |                    |                     |                      |
| s |                    |                     |                      |
| s |                    |                     |                      |
| i |                    |                     |                      |
| s |                    |                     |                      |
| t |                    |                     |                      |
| a |                    |                     |                      |
| n |                    |                     |                      |
| c |                    |                     |                      |
| e |                    |                     |                      |
| A |                    |                     |                      |
| c |                    |                     |                      |
| t |                    |                     |                      |
| i |                    |                     |                      |
| v |                    |                     |                      |
| i |                    |                     |                      |
| t |                    |                     |                      |
| i |                    |                     |                      |
| e |                    |                     |                      |
| s |                    |                     |                      |
| * |                    |                     |                      |
| * |                    |                     |                      |
+---+--------------------+---------------------+----------------------+
| 1 | Housing            |                     |                      |
| 3 | Information        |                     |                      |
| \ | Services           |                     |                      |
| . |                    |                     |                      |
+---+--------------------+---------------------+----------------------+
| 1 | Permanent Housing  |                     |                      |
| 4 | Placement Services |                     |                      |
| \ |                    |                     |                      |
| . |                    |                     |                      |
+---+--------------------+---------------------+----------------------+
| 1 | Adjustment for     |                     |                      |
| 5 | duplication        |                     |                      |
| \ | (subtract)         |                     |                      |
| . |                    |                     |                      |
+---+--------------------+---------------------+----------------------+
| * | **TOTAL Housing    |                     |                      |
| * | Placement          |                     |                      |
| 1 | Assistance**       |                     |                      |
| 6 |                    |                     |                      |
| . |                    |                     |                      |
| * |                    |                     |                      |
| * |                    |                     |                      |
+---+--------------------+---------------------+----------------------+
|   |                    |                     |                      |
+---+--------------------+---------------------+----------------------+
| * |                    | **\[1\] HOPWA       | **\[2\] Amount of    |
| * |                    | Assistance Outputs: | HOPWA Funds          |
| G |                    | Households**        | Expended**           |
| r |                    |                     |                      |
| a |                    |                     |                      |
| n |                    |                     |                      |
| t |                    |                     |                      |
| A |                    |                     |                      |
| d |                    |                     |                      |
| m |                    |                     |                      |
| i |                    |                     |                      |
| n |                    |                     |                      |
| i |                    |                     |                      |
| s |                    |                     |                      |
| t |                    |                     |                      |
| r |                    |                     |                      |
| a |                    |                     |                      |
| t |                    |                     |                      |
| i |                    |                     |                      |
| o |                    |                     |                      |
| n |                    |                     |                      |
| a |                    |                     |                      |
| n |                    |                     |                      |
| d |                    |                     |                      |
| O |                    |                     |                      |
| t |                    |                     |                      |
| h |                    |                     |                      |
| e |                    |                     |                      |
| r |                    |                     |                      |
| A |                    |                     |                      |
| c |                    |                     |                      |
| t |                    |                     |                      |
| i |                    |                     |                      |
| v |                    |                     |                      |
| i |                    |                     |                      |
| t |                    |                     |                      |
| i |                    |                     |                      |
| e |                    |                     |                      |
| s |                    |                     |                      |
| * |                    |                     |                      |
| * |                    |                     |                      |
+---+--------------------+---------------------+----------------------+
| 1 | Resource           |                     |                      |
| 7 | Identification to  |                     |                      |
| \ | establish,         |                     |                      |
| . | coordinate and     |                     |                      |
|   | develop housing    |                     |                      |
|   | assistance         |                     |                      |
|   | resources          |                     |                      |
+---+--------------------+---------------------+----------------------+
| 1 | Technical          |                     |                      |
| 8 | Assistance (if     |                     |                      |
| \ | approved in grant  |                     |                      |
| . | agreement)         |                     |                      |
+---+--------------------+---------------------+----------------------+
| 1 | Project            |                     |                      |
| 9 | Outcomes/Program   |                     |                      |
| \ | Evaluation (if     |                     |                      |
| . | approved in grant  |                     |                      |
|   | agreement)         |                     |                      |
+---+--------------------+---------------------+----------------------+
| 2 | Grantee            |                     |                      |
| 0 | Administration     |                     |                      |
| \ | (maximum 3% of     |                     |                      |
| . | total of HOPWA     |                     |                      |
|   | grant)             |                     |                      |
+---+--------------------+---------------------+----------------------+
| 2 | Project Sponsor    |                     |                      |
| 1 | Administration     |                     |                      |
| \ | (maximum 7% of     |                     |                      |
| . | portion of HOPWA   |                     |                      |
|   | grant awarded)     |                     |                      |
+---+--------------------+---------------------+----------------------+
| 2 | Other Activity (if |                     |                      |
| 2 | approved in grant  |                     |                      |
| \ | agreement).        |                     |                      |
| . | Specify:           |                     |                      |
+---+--------------------+---------------------+----------------------+
| * | **TOTAL Grant      |                     |                      |
| * | Administration and |                     |                      |
| 2 | Other Activities** |                     |                      |
| 3 |                    |                     |                      |
| . |                    |                     |                      |
| * |                    |                     |                      |
| * |                    |                     |                      |
+---+--------------------+---------------------+----------------------+
|   |                    |                     |                      |
+---+--------------------+---------------------+----------------------+
| * |                    |                     | **\[2\] Amount of    |
| * |                    |                     | HOPWA Funds          |
| T |                    |                     | Expended**           |
| O |                    |                     |                      |
| T |                    |                     |                      |
| A |                    |                     |                      |
| L |                    |                     |                      |
| E |                    |                     |                      |
| x |                    |                     |                      |
| p |                    |                     |                      |
| e |                    |                     |                      |
| n |                    |                     |                      |
| d |                    |                     |                      |
| e |                    |                     |                      |
| d |                    |                     |                      |
| * |                    |                     |                      |
| * |                    |                     |                      |
+---+--------------------+---------------------+----------------------+
| * | **TOTAL            |                     |                      |
| * | Expenditures (Sum  |                     |                      |
| 2 | of Rows 6, 9, 12,  |                     |                      |
| 4 | 16 & 23)**         |                     |                      |
| . |                    |                     |                      |
| * |                    |                     |                      |
| * |                    |                     |                      |
+---+--------------------+---------------------+----------------------+

**Part 4: Summary of Performance Outcomes**

**Housing Stability, Prevention of Homelessness, and Access to Care**

> HOPWA Long-term Performance Objective: *Eighty percent of HOPWA
> clients will maintain housing stability, avoid homelessness, and
> access care each year through 2011.*

Section 1. Housing Stability: Assessment of Client Outcomes on
Maintaining Housing Stability

(Permanent Housing and Facilities)

*In Column 1, report the total number of eligible households that
received HOPWA housing assistance, by type. In Column 2, enter the
number of households continuing to access each type of housing
assistance, the following year. In Column 3, report the housing status
of all households that exited the program. Columns 2 (Number of
Households Continuing) and 3 (Exited Households) summed will equal the
total households reported in Column 1. Note: Refer to the destination
codes that appear in Part 6: Appendix: Worksheet on Determining HOPWA
Outcomes and Connections with HMIS (page 24-26).*

+-----------+---------------+---------+---------+-------------+------+
| **\[A\]   | **\[1\] Total | **\[2\] |         | **\[3\]     |      |
| Permanent | Number of     | Asse    |         | Assessment: |      |
| Housing   | Households    | ssment: |         | Number of   |      |
| Ass       | Receiving     | Number  |         | Exited      |      |
| istance** | Housing       | of      |         | Households  |      |
|           | Assistance**  | Hou     |         | and Housing |      |
|           |               | seholds |         | Status**    |      |
|           |               | Con     |         |             |      |
|           |               | tinuing |         |             |      |
|           |               | with    |         |             |      |
|           |               | this    |         |             |      |
|           |               | Housing |         |             |      |
|           |               | (per    |         |             |      |
|           |               | plan or |         |             |      |
|           |               | expe    |         |             |      |
|           |               | ctation |         |             |      |
|           |               | for     |         |             |      |
|           |               | next    |         |             |      |
|           |               | year)** |         |             |      |
+-----------+---------------+---------+---------+-------------+------+
| **Ten     | =             | =       |         | 1 Emergency | =    |
| ant-based |               |         |         | Shel        |      |
| Rental    |               |         |         | ter/Streets |      |
| Ass       |               |         |         |             |      |
| istance** |               |         |         |             |      |
+-----------+---------------+---------+---------+-------------+------+
|           |               |         |         | 2 Temporary | =    |
|           |               |         |         | Housing     |      |
|           |               |         |         |             |      |
+-----------+---------------+---------+---------+-------------+------+
|           |               |         |         | 3 Private   | =    |
|           |               |         |         | Housing     |      |
|           |               |         |         |             |      |
+-----------+---------------+---------+---------+-------------+------+
|           |               |         |         | 4 Other     | =    |
|           |               |         |         | HOPWA       |      |
|           |               |         |         |             |      |
+-----------+---------------+---------+---------+-------------+------+
|           |               |         |         | 5 Other     | =    |
|           |               |         |         | Subsidy     |      |
|           |               |         |         |             |      |
+-----------+---------------+---------+---------+-------------+------+
|           |               |         |         | 6           | =    |
|           |               |         |         | Institution |      |
|           |               |         |         |             |      |
+-----------+---------------+---------+---------+-------------+------+
|           |               |         |         | 7           | =    |
|           |               |         |         | Jail/Prison |      |
|           |               |         |         |             |      |
+-----------+---------------+---------+---------+-------------+------+
|           |               |         |         | 8           | =    |
|           |               |         |         | Disconnec   |      |
|           |               |         |         | ted/Unknown |      |
+-----------+---------------+---------+---------+-------------+------+
|           |               |         |         | 9 Death     | =    |
|           |               |         |         |             |      |
|           |               |         |         |             |      |
+-----------+---------------+---------+---------+-------------+------+
| **        | =             | =       |         | 1 Emergency | =    |
| Permanent |               |         |         | Shel        |      |
| S         |               |         |         | ter/Streets |      |
| upportive |               |         |         |             |      |
| Housing   |               |         |         |             |      |
| Facilitie |               |         |         |             |      |
| s/Units** |               |         |         |             |      |
+-----------+---------------+---------+---------+-------------+------+
|           |               |         |         | 2 Temporary | =    |
|           |               |         |         | Housing     |      |
|           |               |         |         |             |      |
+-----------+---------------+---------+---------+-------------+------+
|           |               |         |         | 3 Private   | =    |
|           |               |         |         | Housing     |      |
|           |               |         |         |             |      |
+-----------+---------------+---------+---------+-------------+------+
|           |               |         |         | 4 Other     | =    |
|           |               |         |         | HOPWA       |      |
|           |               |         |         |             |      |
+-----------+---------------+---------+---------+-------------+------+
|           |               |         |         | 5 Other     | =    |
|           |               |         |         | Subsidy     |      |
|           |               |         |         |             |      |
+-----------+---------------+---------+---------+-------------+------+
|           |               |         |         | 6           | =    |
|           |               |         |         | Institution |      |
|           |               |         |         |             |      |
+-----------+---------------+---------+---------+-------------+------+
|           |               |         |         | 7           | =    |
|           |               |         |         | Jail/Prison |      |
|           |               |         |         |             |      |
+-----------+---------------+---------+---------+-------------+------+
|           |               |         |         | 8           | =    |
|           |               |         |         | Disconnec   |      |
|           |               |         |         | ted/Unknown |      |
+-----------+---------------+---------+---------+-------------+------+
|           |               |         |         | 9 Death     | =    |
|           |               |         |         |             |      |
|           |               |         |         |             |      |
+-----------+---------------+---------+---------+-------------+------+
|           |               |         |         |             |      |
+-----------+---------------+---------+---------+-------------+------+
| **\[B\]   | **\[1\] Total | **\[2\] |         | **\[3\]     |      |
| Tra       | Number of     | Of the  |         | Assessment: |      |
| nsitional | Households    | Total   |         | Number of   |      |
| Housing   | Receiving     | Number  |         | Exited      |      |
| Ass       | Housing       | of      |         | Households  |      |
| istance** | Assistance**  | Hou     |         | and Housing |      |
|           |               | seholds |         | Status**    |      |
|           |               | Re      |         |             |      |
|           |               | ceiving |         |             |      |
|           |               | Housing |         |             |      |
|           |               | Ass     |         |             |      |
|           |               | istance |         |             |      |
|           |               | this    |         |             |      |
|           |               | Op      |         |             |      |
|           |               | erating |         |             |      |
|           |               | Year**  |         |             |      |
+-----------+---------------+---------+---------+-------------+------+
| **        | =             | Total   | =       | 1 Emergency | =    |
| Transitio |               | number  |         | Shel        |      |
| nal/Short |               | of      | =       | ter/Streets |      |
| term      |               | hou     |         |             |      |
| Support   |               | seholds |         |             |      |
| Facilitie |               | that    |         |             |      |
| s/Units** |               | will    |         |             |      |
|           |               | c       |         |             |      |
|           |               | ontinue |         |             |      |
|           |               | in      |         |             |      |
|           |               | resi    |         |             |      |
|           |               | dences: |         |             |      |
|           |               |         |         |             |      |
|           |               | Total   |         |             |      |
|           |               | number  |         |             |      |
|           |               | of      |         |             |      |
|           |               | hou     |         |             |      |
|           |               | seholds |         |             |      |
|           |               | whose   |         |             |      |
|           |               | tenure  |         |             |      |
|           |               | e       |         |             |      |
|           |               | xceeded |         |             |      |
|           |               | 24      |         |             |      |
|           |               | months  |         |             |      |
+-----------+---------------+---------+---------+-------------+------+
|           |               |         |         | 2 Temporary | =    |
|           |               |         |         | Housing     |      |
|           |               |         |         |             |      |
+-----------+---------------+---------+---------+-------------+------+
|           |               |         |         | 3 Private   | =    |
|           |               |         |         | Housing     |      |
|           |               |         |         |             |      |
+-----------+---------------+---------+---------+-------------+------+
|           |               |         |         | 4 Other     | =    |
|           |               |         |         | HOPWA       |      |
|           |               |         |         |             |      |
+-----------+---------------+---------+---------+-------------+------+
|           |               |         |         | 5 Other     | =    |
|           |               |         |         | Subsidy     |      |
|           |               |         |         |             |      |
+-----------+---------------+---------+---------+-------------+------+
|           |               |         |         | 6           | =    |
|           |               |         |         | Institution |      |
|           |               |         |         |             |      |
+-----------+---------------+---------+---------+-------------+------+
|           |               |         |         | 7           | =    |
|           |               |         |         | Jail/Prison |      |
|           |               |         |         |             |      |
+-----------+---------------+---------+---------+-------------+------+
|           |               |         |         | 8           | =    |
|           |               |         |         | Disconnec   |      |
|           |               |         |         | ted/unknown |      |
+-----------+---------------+---------+---------+-------------+------+
|           |               |         |         | 9 Death     | =    |
|           |               |         |         |             |      |
|           |               |         |         |             |      |
+-----------+---------------+---------+---------+-------------+------+

**Section 2. Prevention of Homelessness:** **Assessment of Client
Outcomes on reduced risks of homelessness (Short-Term Housing
Assistance)**

Report the total number of households that received STRMU assistance in
Column 1. In Column 2, identify the result of the housing assessment
made at time of assistance, or updated in the operating year. (Column 3
provides a description of housing outcomes; therefore, data is not
required.) In Row 1a, enter the total number of households served in the
prior operating year that received STRMU assistance this year. In Row
1b, enter the total number of households that received STRMU Assistance
in the 2 prior operating years that received STRMU assistance this year.
*Note:* *The sum of Column 2 should equal the number of households
reported in Column 1*.

**Assessment of Households receiving STRMU Assistance**

  -------------- --------------------------- ------- ------------------- -------------
  **\[1\] STRMU  **\[2\] Assessment of               **\[3\] HOPWA       
  Housing        Housing Status**                    Client Outcomes**   
  Assistance**                                                           

  =              Maintain private housing    =       *Stable/Permanent   
                 without subsidy (*e.g.              Housing (PH)*       
                 Assistance                                              
                 provided/completed and                                  
                 client is stable, not                                   
                 likely to seek additional                               
                 support*)                                               

                 Other Private Housing       =                           
                 without subsidy                                         

                 Other HOPWA support (PH)    =                           

                 Other housing subsidy (PH)  =                           

                 Institution (*e.g.          =                           
                 residential and long-term                               
                 care*)                                                  

                                                                         

                 Likely to maintain current  =       *Temporarily        
                 housing arrangements, with          Stable, with        
                 additional STRMU assistance         Reduced Risk of     
                                                     Homelessness*       

                 Transitional                =                           
                 Facilities/Short-term (e.g.                             
                 *temporary or transitional                              
                 arrangement*)                                           

                 Temporary/Non-Permanent     =                           
                 Housing arrangement (*e.g.                              
                 gave up lease, and moved in                             
                 with family or friends but                              
                 expects to live there less                              
                 than 90 days*)                                          

                                                                         

                 Emergency Shelter/street    =       *Unstable           
                                                     Arrangements*       

                 Jail/Prison                 =                           

                 Disconnected                =                           

                                                                         

                 Death                       =       *Life Event*        

  1a. Total                                                              =      
  number of                                                              
  those                                                                  
  households                                                             
  that received                                                          
  STRMU                                                                  
  Assistance in                                                          
  the prior                                                              
  operating                                                              
  year, that                                                             
  received STRMU                                                         
  assistance in                                                          
  the current                                                            
  operating year                                                         

  1b. Total                                                              =      
  number of                                                              
  those                                                                  
  households                                                             
  that received                                                          
  STRMU                                                                  
  Assistance in                                                          
  the two (2                                                             
  years ago)                                                             
  prior                                                                  
  operating                                                              
  years, that                                                            
  received STRMU                                                         
  assistance in                                                          
  the current                                                            
  operating year                                                         
  -------------- --------------------------- ------- ------------------- -------------

**Section 3. Access to Care and Support: Assessment of Client Outcomes
on Access to Care and Support**

# **1A. Status of Households Accessing Care and Support by Project Sponsors delivering HOPWA Housing Assistance/Housing Placement/Case Management**

Use Table 1A for project sponsors that provide housing
assistance/housing placement with or without case management services.
In Table 1A, identify the number of client households receiving any type
of HOPWA housing assistance that demonstrated improved access or
maintained connections to care and support within the program year by:
having a housing plan; having contact with a case manager/benefits
counselor; visiting a primary health care provider; accessing medical
insurance/assistance; and accessing or qualifying for income benefits.
*Note: For information on types and sources of income and medical
insurance/assistance, refer to Charts 1C and 1D.*

+-------------------------------------+-----------------------+--------+
| ##                                  | **Households          | **O    |
| **Categories of Services Accessed** | Receiving Housing     | utcome |
|                                     | Assistance within the | Indic  |
|                                     | Operating Year**      | ator** |
+-------------------------------------+-----------------------+--------+
| 1\. Has a housing plan for          |                       | *S     |
| maintaining or establishing stable  |                       | upport |
| on-going housing                    |                       | for    |
|                                     |                       | Stable |
|                                     |                       | Ho     |
|                                     |                       | using* |
+-------------------------------------+-----------------------+--------+
| 2\. Has contact with case           |                       | *      |
| manager/benefits counselor          |                       | Access |
| consistent with the schedule        |                       | to     |
| specified in client's individual    |                       | Su     |
| service plan.                       |                       | pport* |
+-------------------------------------+-----------------------+--------+
| 3\. Had contact with a primary      |                       | *      |
| health care provider consistent     |                       | Access |
| with the schedule specified in      |                       | to     |
| client's individual service plan.   |                       | Health |
|                                     |                       | Care*  |
+-------------------------------------+-----------------------+--------+
| 4\. Has accessed and can maintain   |                       | *      |
| medical insurance/assistance.       |                       | Access |
|                                     |                       | to     |
|                                     |                       | Health |
|                                     |                       | Care*  |
+-------------------------------------+-----------------------+--------+
| 5\. Successfully accessed or        |                       | *S     |
| maintained qualification for        |                       | ources |
| sources of income.                  |                       | of     |
|                                     |                       | I      |
|                                     |                       | ncome* |
+-------------------------------------+-----------------------+--------+

# **1B. Number of Households Obtaining Employment** 

In Table 1B, identify the number of recipient households that include
persons who obtained an income-producing job during the operating year
that resulted from HOPWA funded: job training, employment assistance,
education or related case management/counseling services. *Note: This
includes jobs created by this project sponsor or obtained outside this
agency.*

  -------------------------------------- ----------------------- -------------
  **Categories of Services Accessed**    **Number of Households  **Outcome
                                         that Obtained           Indicator**
                                         Employment**            

  Total number of households that                                *Sources of
  obtained an income-producing job                               Income*
  -------------------------------------- ----------------------- -------------

**Chart 1C: Sources of income include, but are not limited to the
following *(Reference only)***

+------------------------------------+---------------------------------+
| -   Earned Income                  | -   Veteran's Pension           |
+------------------------------------+---------------------------------+
| -   Unemployment Insurance         | -   Pension from Former Job     |
+------------------------------------+---------------------------------+
| -   Supplemental Security Income   | -   Child Support               |
|     (SSI)                          |                                 |
+------------------------------------+---------------------------------+
| -   Social Security Disability     | -   Alimony or other Spousal    |
|     Income (SSDI)                  |     Support                     |
+------------------------------------+---------------------------------+
| -   Veteran's Disability Payment   | -   Retirement Income from      |
|                                    |     Social Security             |
+------------------------------------+---------------------------------+
| -   General Assistance, or use     | -   Private Disability          |
|     local program name             |     Insurance                   |
+------------------------------------+---------------------------------+
| -   Temporary Assistance for Needy | -   Worker's Compensation       |
|     Families                       |                                 |
|                                    |                                 |
| > (TANF) income, or use local      |                                 |
| > program name                     |                                 |
+------------------------------------+---------------------------------+

**Chart 1D: Sources of medical insurance and assistance include, but are
not limited to the following *(Reference only)***

+------------------------------------+---------------------------------+
| -   MEDICAID Health Insurance      | -   MEDICARE Health Insurance   |
|     Program, or use local program  |     Program, or use local       |
|                                    |     program name                |
| > name                             |                                 |
+------------------------------------+---------------------------------+
| -   Veterans Affairs Medical       | -   AIDS Drug Assistance        |
|     Services                       |     Program (ADAP)              |
+------------------------------------+---------------------------------+
| -   State Children's Health        | -   Ryan White-funded Medical   |
|     Insurance Program (SCHIP), or  |     or Dental Assistance        |
|     use local                      |                                 |
|                                    |                                 |
| > program name                     |                                 |
+------------------------------------+---------------------------------+

# 

# **2A. Status of Households Accessing Care and Support through HOPWA-funded Services receiving Housing Assistance from Other Sources** 

In Table 2A, identify the number of client households receiving
HOPWA-funded housing placement or case management services who have
other housing arrangements that demonstrated improved access or
maintained connections to care and support within the program year by:
having a housing plan; having contact with a case manager/benefits
counselor; visiting a primary health care provider; accessing medical
insurance/assistance; and accessing or qualifying for income benefits.
*Note: For information on types and sources of income and medical
insurance/assistance, refer to Charts 2C and 2D.*

+-------------------------------------+-----------------------+--------+
| ##                                  | **Households          | **O    |
| **Categories of Services Accessed** | Receiving HOPWA       | utcome |
|                                     | Assistance within the | Indic  |
|                                     | Operating Year**      | ator** |
+-------------------------------------+-----------------------+--------+
| 1\. Has a housing plan for          |                       | *S     |
| maintaining or establishing stable  |                       | upport |
| on-going housing.                   |                       | for    |
|                                     |                       | Stable |
|                                     |                       | Ho     |
|                                     |                       | using* |
+-------------------------------------+-----------------------+--------+
| 2\. Has contact with case           |                       | *      |
| manager/benefits counselor          |                       | Access |
| consistent with the schedule        |                       | to     |
| specified in client's individual    |                       | Su     |
| service plan.                       |                       | pport* |
+-------------------------------------+-----------------------+--------+
| 3\. Had contact with a primary      |                       | *      |
| health care provider consistent     |                       | Access |
| with the schedule specified in      |                       | to     |
| clients individual service plan.    |                       | Health |
|                                     |                       | Care*  |
+-------------------------------------+-----------------------+--------+
| 4\. Has accessed and can maintain   |                       | *      |
| medical insurance/assistance.       |                       | Access |
|                                     |                       | to     |
|                                     |                       | Health |
|                                     |                       | Care*  |
+-------------------------------------+-----------------------+--------+
| 5\. Successfully accessed or        |                       | *S     |
| maintained qualification for        |                       | ources |
| sources of income.                  |                       | of     |
|                                     |                       | I      |
|                                     |                       | ncome* |
+-------------------------------------+-----------------------+--------+

# **Chart 2B. Number of Households Obtaining Employment** 

In Table 2B, identify the number of recipient households that include
persons who obtained an income-producing job during the operating year
that resulted from HOPWA funded: job training, employment assistance,
education or related case management/counseling services. *Note: This
includes jobs created by this project sponsor or obtained outside this
agency.*

  --------------------------------------- ---------------------- -------------
  **Categories of Services Accessed**     **Number of Households **Outcome
                                          that Obtained          Indicator**
                                          Employme**nt           

  Total number of households that                                *Sources of
  obtained an income-producing job                               Income*
  --------------------------------------- ---------------------- -------------

**Chart 2C: Sources of income include, but are not limited to the
following *(Reference only)***

+------------------------------------+---------------------------------+
| -   Earned Income                  | -   Veteran's Pension           |
+------------------------------------+---------------------------------+
| -   Unemployment Insurance         | -   Pension from Former Job     |
+------------------------------------+---------------------------------+
| -   Supplemental Security Income   | -   Child Support               |
|     (SSI)                          |                                 |
+------------------------------------+---------------------------------+
| -   Social Security Disability     | -   Alimony or other Spousal    |
|     Income (SSDI)                  |     Support                     |
+------------------------------------+---------------------------------+
| -   Veteran's Disability Payment   | -   Retirement Income from      |
|                                    |     Social Security             |
+------------------------------------+---------------------------------+
| -   General Assistance, or use     | -   Private Disability          |
|     local program name             |     Insurance                   |
+------------------------------------+---------------------------------+
| -   Temporary Assistance for Needy | -   Worker's Compensation       |
|     Families                       |                                 |
|                                    |                                 |
| > (TANF) income, or use local      |                                 |
| > program name                     |                                 |
+------------------------------------+---------------------------------+

**2D: Sources of medical insurance and assistance include, but are not
limited to the following *(Reference only)***

+------------------------------------+---------------------------------+
| -   MEDICAID Health Insurance      | -   MEDICARE Health Insurance   |
|     Program, or use local program  |     Program, or use local       |
|                                    |     program name                |
| > name                             |                                 |
+------------------------------------+---------------------------------+
| -   Veterans Affairs Medical       | -   AIDS Drug Assistance        |
|     Services                       |     Program (ADAP)              |
+------------------------------------+---------------------------------+
| -   State Children's Health        | -   Ryan White-funded Medical   |
|     Insurance Program (SCHIP), or  |     or Dental Assistance        |
|     use local                      |                                 |
|                                    |                                 |
| > program name                     |                                 |
+------------------------------------+---------------------------------+

**Part 5A: Summary of Project Sponsor Information**

In Chart 1, provide the following information for [each]{.underline}
organization designated or selected to serve as a project sponsor, as
defined by CFR 574.3. Complete and attach the respective performance
sections (PART 5B-5F) for each HOPWA funded activity. In addition, if a
subrecipient assists in carrying out the project sponsor functions,
report on these organizations with a contract/agreement of \$25,000 or
greater from the sponsor in Chart 2. Agreements include: grants,
subgrants, loans, awards, cooperative agreements, and other foams of
financial assistance; and contracts, subcontracts, purchase orders, task
orders, and delivery orders. For example, use this section to report on
organizations involved in any aspect of service delivery for
beneficiaries. These elements address requirements in the Federal
Financial Accountability and Transparency Act of 2006 (Public Law
109-282). *Note: If the grantee undertakes service delivery activities
directly, complete the respective performance sections (PART 5B-5F) for
all activities conducted by the grantee.*

**1. Project Sponsor Information**

+----------------------+-----------+---+---+---------+---+---+-----+------------+
| **Project Sponsor    |           | * |   |         |   |   |     |            |
| Agency Name**        |           | * |   |         |   |   |     |            |
|                      |           | P |   |         |   |   |     |            |
|                      |           | a |   |         |   |   |     |            |
|                      |           | r |   |         |   |   |     |            |
|                      |           | e |   |         |   |   |     |            |
|                      |           | n |   |         |   |   |     |            |
|                      |           | t |   |         |   |   |     |            |
|                      |           | C |   |         |   |   |     |            |
|                      |           | o |   |         |   |   |     |            |
|                      |           | m |   |         |   |   |     |            |
|                      |           | p |   |         |   |   |     |            |
|                      |           | a |   |         |   |   |     |            |
|                      |           | n |   |         |   |   |     |            |
|                      |           | y |   |         |   |   |     |            |
|                      |           | N |   |         |   |   |     |            |
|                      |           | a |   |         |   |   |     |            |
|                      |           | m |   |         |   |   |     |            |
|                      |           | e |   |         |   |   |     |            |
|                      |           | * |   |         |   |   |     |            |
|                      |           | , |   |         |   |   |     |            |
|                      |           | i |   |         |   |   |     |            |
|                      |           | f |   |         |   |   |     |            |
|                      |           | a |   |         |   |   |     |            |
|                      |           | p |   |         |   |   |     |            |
|                      |           | p |   |         |   |   |     |            |
|                      |           | l |   |         |   |   |     |            |
|                      |           | i |   |         |   |   |     |            |
|                      |           | c |   |         |   |   |     |            |
|                      |           | a |   |         |   |   |     |            |
|                      |           | b |   |         |   |   |     |            |
|                      |           | l |   |         |   |   |     |            |
|                      |           | e |   |         |   |   |     |            |
|                      |           | * |   |         |   |   |     |            |
|                      |           | * |   |         |   |   |     |            |
|                      |           | * |   |         |   |   |     |            |
|                      |           |   |   |         |   |   |     |            |
|                      |           |   |   |         |   |   |     |            |
|                      |           |   |   |         |   |   |     |            |
|                      |           |   |   |         |   |   |     |            |
|                      |           |   |   |         |   |   |     |            |
|                      |           |   |   |         |   |   |     |            |
+----------------------+-----------+---+---+---------+---+---+-----+------------+
| **Name and Title of  |           |   |   |         |   |   |     |            |
| Contact at Project   |           |   |   |         |   |   |     |            |
| Sponsor Agency**     |           |   |   |         |   |   |     |            |
+----------------------+-----------+---+---+---------+---+---+-----+------------+
| **Email Address**    |           |   |   |         |   |   |     |            |
+----------------------+-----------+---+---+---------+---+---+-----+------------+
| **Business Address** |           |   |   |         |   |   |     |            |
+----------------------+-----------+---+---+---------+---+---+-----+------------+
| **City, County,      |           |   |   |         |   |   |     |            |
| State, Zip,**        |           |   |   |         |   |   |     |            |
+----------------------+-----------+---+---+---------+---+---+-----+------------+
| **Phone Number       |           |   |   |         | * |   |     |            |
| *(with area code*)** |           |   |   |         | * |   |     |            |
|                      |           |   |   |         | F |   |     |            |
|                      |           |   |   |         | a |   |     |            |
|                      |           |   |   |         | x |   |     |            |
|                      |           |   |   |         | N |   |     |            |
|                      |           |   |   |         | u |   |     |            |
|                      |           |   |   |         | m |   |     |            |
|                      |           |   |   |         | b |   |     |            |
|                      |           |   |   |         | e |   |     |            |
|                      |           |   |   |         | r |   |     |            |
|                      |           |   |   |         | ( |   |     |            |
|                      |           |   |   |         | w |   |     |            |
|                      |           |   |   |         | i |   |     |            |
|                      |           |   |   |         | t |   |     |            |
|                      |           |   |   |         | h |   |     |            |
|                      |           |   |   |         | a |   |     |            |
|                      |           |   |   |         | r |   |     |            |
|                      |           |   |   |         | e |   |     |            |
|                      |           |   |   |         | a |   |     |            |
|                      |           |   |   |         | c |   |     |            |
|                      |           |   |   |         | o |   |     |            |
|                      |           |   |   |         | d |   |     |            |
|                      |           |   |   |         | e |   |     |            |
|                      |           |   |   |         | ) |   |     |            |
|                      |           |   |   |         | * |   |     |            |
|                      |           |   |   |         | * |   |     |            |
|                      |           |   |   |         |   |   |     |            |
|                      |           |   |   |         |   |   |     |            |
|                      |           |   |   |         |   |   |     |            |
|                      |           |   |   |         |   |   |     |            |
|                      |           |   |   |         |   |   |     |            |
|                      |           |   |   |         |   |   |     |            |
+----------------------+-----------+---+---+---------+---+---+-----+------------+
| **Employer           |           |   |   |         | * |   |     |            |
| Identification       |           |   |   |         | * |   |     |            |
| Number (EIN) or**    |           |   |   |         | D |   |     |            |
|                      |           |   |   |         | U |   |     |            |
| **Tax Identification |           |   |   |         | N |   |     |            |
| Number (TIN)**       |           |   |   |         | & |   |     |            |
|                      |           |   |   |         | B |   |     |            |
|                      |           |   |   |         | r |   |     |            |
|                      |           |   |   |         | a |   |     |            |
|                      |           |   |   |         | d |   |     |            |
|                      |           |   |   |         | s |   |     |            |
|                      |           |   |   |         | t |   |     |            |
|                      |           |   |   |         | r |   |     |            |
|                      |           |   |   |         | e |   |     |            |
|                      |           |   |   |         | e |   |     |            |
|                      |           |   |   |         | t |   |     |            |
|                      |           |   |   |         | N |   |     |            |
|                      |           |   |   |         | u |   |     |            |
|                      |           |   |   |         | m |   |     |            |
|                      |           |   |   |         | b |   |     |            |
|                      |           |   |   |         | e |   |     |            |
|                      |           |   |   |         | r |   |     |            |
|                      |           |   |   |         | ( |   |     |            |
|                      |           |   |   |         | D |   |     |            |
|                      |           |   |   |         | U |   |     |            |
|                      |           |   |   |         | N |   |     |            |
|                      |           |   |   |         | s |   |     |            |
|                      |           |   |   |         | ) |   |     |            |
|                      |           |   |   |         | * |   |     |            |
|                      |           |   |   |         | i |   |     |            |
|                      |           |   |   |         | f |   |     |            |
|                      |           |   |   |         | a |   |     |            |
|                      |           |   |   |         | p |   |     |            |
|                      |           |   |   |         | p |   |     |            |
|                      |           |   |   |         | l |   |     |            |
|                      |           |   |   |         | i |   |     |            |
|                      |           |   |   |         | c |   |     |            |
|                      |           |   |   |         | a |   |     |            |
|                      |           |   |   |         | b |   |     |            |
|                      |           |   |   |         | l |   |     |            |
|                      |           |   |   |         | e |   |     |            |
|                      |           |   |   |         | * |   |     |            |
|                      |           |   |   |         | * |   |     |            |
|                      |           |   |   |         | * |   |     |            |
|                      |           |   |   |         |   |   |     |            |
|                      |           |   |   |         |   |   |     |            |
|                      |           |   |   |         |   |   |     |            |
|                      |           |   |   |         |   |   |     |            |
|                      |           |   |   |         |   |   |     |            |
|                      |           |   |   |         |   |   |     |            |
+----------------------+-----------+---+---+---------+---+---+-----+------------+
| **Congressional      |           |   |   |         |   |   |     |            |
| District of Business |           |   |   |         |   |   |     |            |
| Location of          |           |   |   |         |   |   |     |            |
| Sponsor**            |           |   |   |         |   |   |     |            |
+----------------------+-----------+---+---+---------+---+---+-----+------------+
| **Congressional      |           |   |   |         |   |   |     |            |
| District(s) of       |           |   |   |         |   |   |     |            |
| Primary Service      |           |   |   |         |   |   |     |            |
| Area(s)**            |           |   |   |         |   |   |     |            |
+----------------------+-----------+---+---+---------+---+---+-----+------------+
| **Zip Code(s) of     |           |   |   |         |   |   |     |            |
| Primary Service      |           |   |   |         |   |   |     |            |
| Area(s)**            |           |   |   |         |   |   |     |            |
+----------------------+-----------+---+---+---------+---+---+-----+------------+
| **City(ies) and      |           |   |   |         |   |   |     |            |
| County(ies) of       |           |   |   |         |   |   |     |            |
| Primary Service      |           |   |   |         |   |   |     |            |
| Area(s)**            |           |   |   |         |   |   |     |            |
|                      |           |   |   |         |   |   |     |            |
+----------------------+-----------+---+---+---------+---+---+-----+------------+
| **Total HOPWA        |           |   |   |         |   |   |     |            |
| contract amount for  |           |   |   |         |   |   |     |            |
| this Organization**  |           |   |   |         |   |   |     |            |
+----------------------+-----------+---+---+---------+---+---+-----+------------+
| **Organization's     |           |   | * |         |   |   |     |            |
| Website Address**    |           |   | * |         |   |   |     |            |
|                      |           |   | D |         |   |   |     |            |
|                      |           |   | o |         |   |   |     |            |
|                      |           |   | e |         |   |   |     |            |
|                      |           |   | s |         |   |   |     |            |
|                      |           |   | y |         |   |   |     |            |
|                      |           |   | o |         |   |   |     |            |
|                      |           |   | u |         |   |   |     |            |
|                      |           |   | r |         |   |   |     |            |
|                      |           |   | o |         |   |   |     |            |
|                      |           |   | r |         |   |   |     |            |
|                      |           |   | g |         |   |   |     |            |
|                      |           |   | a |         |   |   |     |            |
|                      |           |   | n |         |   |   |     |            |
|                      |           |   | i |         |   |   |     |            |
|                      |           |   | z |         |   |   |     |            |
|                      |           |   | a |         |   |   |     |            |
|                      |           |   | t |         |   |   |     |            |
|                      |           |   | i |         |   |   |     |            |
|                      |           |   | o |         |   |   |     |            |
|                      |           |   | n |         |   |   |     |            |
|                      |           |   | m |         |   |   |     |            |
|                      |           |   | a |         |   |   |     |            |
|                      |           |   | i |         |   |   |     |            |
|                      |           |   | n |         |   |   |     |            |
|                      |           |   | t |         |   |   |     |            |
|                      |           |   | a |         |   |   |     |            |
|                      |           |   | i |         |   |   |     |            |
|                      |           |   | n |         |   |   |     |            |
|                      |           |   | a |         |   |   |     |            |
|                      |           |   | w |         |   |   |     |            |
|                      |           |   | a |         |   |   |     |            |
|                      |           |   | i |         |   |   |     |            |
|                      |           |   | t |         |   |   |     |            |
|                      |           |   | i |         |   |   |     |            |
|                      |           |   | n |         |   |   |     |            |
|                      |           |   | g |         |   |   |     |            |
|                      |           |   | l |         |   |   |     |            |
|                      |           |   | i |         |   |   |     |            |
|                      |           |   | s |         |   |   |     |            |
|                      |           |   | t |         |   |   |     |            |
|                      |           |   | ? |         |   |   |     |            |
|                      |           |   | * |         |   |   |     |            |
|                      |           |   | * |         |   |   |     |            |
|                      |           |   | Y |         |   |   |     |            |
|                      |           |   | e |         |   |   |     |            |
|                      |           |   | s |         |   |   |     |            |
|                      |           |   | N |         |   |   |     |            |
|                      |           |   | o |         |   |   |     |            |
+----------------------+-----------+---+---+---------+---+---+-----+------------+
| **Is the sponsor a   |           |   |   |         |   |   |     |            |
| nonprofit            |           |   |   |         |   |   |     |            |
| organization?**      |           |   |   |         |   |   |     |            |
| **Yes** **No**       |           |   |   |         |   |   |     |            |
|                      |           |   |   |         |   |   |     |            |
| *Please check if yes |           |   |   |         |   |   |     |            |
| and a faith-based    |           |   |   |         |   |   |     |            |
| organization.*       |           |   |   |         |   |   |     |            |
|                      |           |   |   |         |   |   |     |            |
| *Please check if yes |           |   |   |         |   |   |     |            |
| and a grassroots     |           |   |   |         |   |   |     |            |
| organization.*       |           |   |   |         |   |   |     |            |
+----------------------+-----------+---+---+---------+---+---+-----+------------+

**2. Subrecipient Information/Sponsor Activities**

Provide the following information for [each]{.underline} organization
with a contract/agreement of \$25,000 or greater that assist project
sponsor carrying out project sponsor functions. For example, use this
section to report on organizations involved in an aspect of service
delivery for beneficiaries. Organizations listed may have contracts with
project sponsors or other organizations beside the grantee. Agreements
include: grants, subgrants, loans, awards, cooperative agreements, and
other foams of financial assistance; and contracts, subcontracts,
purchase orders, task orders, and delivery orders.

+----------------------+------------+------+---+---+---+-----+------------+
| **Subrecipient       |            |      | * |   |   |     |            |
| Name**               |            |      | * |   |   |     |            |
|                      |            |      | P |   |   |     |            |
|                      |            |      | a |   |   |     |            |
|                      |            |      | r |   |   |     |            |
|                      |            |      | e |   |   |     |            |
|                      |            |      | n |   |   |     |            |
|                      |            |      | t |   |   |     |            |
|                      |            |      | C |   |   |     |            |
|                      |            |      | o |   |   |     |            |
|                      |            |      | m |   |   |     |            |
|                      |            |      | p |   |   |     |            |
|                      |            |      | a |   |   |     |            |
|                      |            |      | n |   |   |     |            |
|                      |            |      | y |   |   |     |            |
|                      |            |      | N |   |   |     |            |
|                      |            |      | a |   |   |     |            |
|                      |            |      | m |   |   |     |            |
|                      |            |      | e |   |   |     |            |
|                      |            |      | , |   |   |     |            |
|                      |            |      | * |   |   |     |            |
|                      |            |      | i |   |   |     |            |
|                      |            |      | f |   |   |     |            |
|                      |            |      | a |   |   |     |            |
|                      |            |      | p |   |   |     |            |
|                      |            |      | p |   |   |     |            |
|                      |            |      | l |   |   |     |            |
|                      |            |      | i |   |   |     |            |
|                      |            |      | c |   |   |     |            |
|                      |            |      | a |   |   |     |            |
|                      |            |      | b |   |   |     |            |
|                      |            |      | l |   |   |     |            |
|                      |            |      | e |   |   |     |            |
|                      |            |      | * |   |   |     |            |
|                      |            |      | * |   |   |     |            |
|                      |            |      | * |   |   |     |            |
|                      |            |      |   |   |   |     |            |
|                      |            |      |   |   |   |     |            |
|                      |            |      |   |   |   |     |            |
|                      |            |      |   |   |   |     |            |
|                      |            |      |   |   |   |     |            |
|                      |            |      |   |   |   |     |            |
+----------------------+------------+------+---+---+---+-----+------------+
| **Name and Title of  |            |      |   |   |   |     |            |
| Contact at           |            |      |   |   |   |     |            |
| Contractor/**        |            |      |   |   |   |     |            |
|                      |            |      |   |   |   |     |            |
| **Sub-contractor     |            |      |   |   |   |     |            |
| Agency**             |            |      |   |   |   |     |            |
+----------------------+------------+------+---+---+---+-----+------------+
| **Email Address**    |            |      |   |   |   |     |            |
+----------------------+------------+------+---+---+---+-----+------------+
| **Business Address** |            |      |   |   |   |     |            |
+----------------------+------------+------+---+---+---+-----+------------+
| **City, County,      |            |      |   |   |   |     |            |
| State, Zip**         |            |      |   |   |   |     |            |
+----------------------+------------+------+---+---+---+-----+------------+
| **Phone Number       |            |      |   | * |   |     |            |
| (included area       |            |      |   | * |   |     |            |
| code)**              |            |      |   | F |   |     |            |
|                      |            |      |   | a |   |     |            |
|                      |            |      |   | x |   |     |            |
|                      |            |      |   | N |   |     |            |
|                      |            |      |   | u |   |     |            |
|                      |            |      |   | m |   |     |            |
|                      |            |      |   | b |   |     |            |
|                      |            |      |   | e |   |     |            |
|                      |            |      |   | r |   |     |            |
|                      |            |      |   | ( |   |     |            |
|                      |            |      |   | i |   |     |            |
|                      |            |      |   | n |   |     |            |
|                      |            |      |   | c |   |     |            |
|                      |            |      |   | l |   |     |            |
|                      |            |      |   | u |   |     |            |
|                      |            |      |   | d |   |     |            |
|                      |            |      |   | e |   |     |            |
|                      |            |      |   | a |   |     |            |
|                      |            |      |   | r |   |     |            |
|                      |            |      |   | e |   |     |            |
|                      |            |      |   | a |   |     |            |
|                      |            |      |   | c |   |     |            |
|                      |            |      |   | o |   |     |            |
|                      |            |      |   | d |   |     |            |
|                      |            |      |   | e |   |     |            |
|                      |            |      |   | ) |   |     |            |
|                      |            |      |   | * |   |     |            |
|                      |            |      |   | * |   |     |            |
|                      |            |      |   |   |   |     |            |
|                      |            |      |   |   |   |     |            |
|                      |            |      |   |   |   |     |            |
|                      |            |      |   |   |   |     |            |
|                      |            |      |   |   |   |     |            |
|                      |            |      |   |   |   |     |            |
+----------------------+------------+------+---+---+---+-----+------------+
| **Employer           |            |      | * |   |   |     |            |
| Identification       |            |      | * |   |   |     |            |
| Number (EIN) or**    |            |      | D |   |   |     |            |
|                      |            |      | u |   |   |     |            |
| **Tax Identification |            |      | n |   |   |     |            |
| Number (TIN)**       |            |      | & |   |   |     |            |
|                      |            |      | B |   |   |     |            |
|                      |            |      | r |   |   |     |            |
|                      |            |      | a |   |   |     |            |
|                      |            |      | d |   |   |     |            |
|                      |            |      | s |   |   |     |            |
|                      |            |      | t |   |   |     |            |
|                      |            |      | r |   |   |     |            |
|                      |            |      | e |   |   |     |            |
|                      |            |      | e |   |   |     |            |
|                      |            |      | t |   |   |     |            |
|                      |            |      | ( |   |   |     |            |
|                      |            |      | D |   |   |     |            |
|                      |            |      | U |   |   |     |            |
|                      |            |      | N |   |   |     |            |
|                      |            |      | s |   |   |     |            |
|                      |            |      | ) |   |   |     |            |
|                      |            |      | , |   |   |     |            |
|                      |            |      | * |   |   |     |            |
|                      |            |      | i |   |   |     |            |
|                      |            |      | f |   |   |     |            |
|                      |            |      | a |   |   |     |            |
|                      |            |      | p |   |   |     |            |
|                      |            |      | p |   |   |     |            |
|                      |            |      | l |   |   |     |            |
|                      |            |      | i |   |   |     |            |
|                      |            |      | c |   |   |     |            |
|                      |            |      | a |   |   |     |            |
|                      |            |      | b |   |   |     |            |
|                      |            |      | l |   |   |     |            |
|                      |            |      | e |   |   |     |            |
|                      |            |      | * |   |   |     |            |
|                      |            |      | * |   |   |     |            |
|                      |            |      | * |   |   |     |            |
|                      |            |      |   |   |   |     |            |
|                      |            |      |   |   |   |     |            |
|                      |            |      |   |   |   |     |            |
|                      |            |      |   |   |   |     |            |
|                      |            |      |   |   |   |     |            |
|                      |            |      |   |   |   |     |            |
+----------------------+------------+------+---+---+---+-----+------------+
| **North American     |            |      |   |   |   |     |            |
| Industry             |            |      |   |   |   |     |            |
| Classification       |            |      |   |   |   |     |            |
| System (NAICS)       |            |      |   |   |   |     |            |
| Code**               |            |      |   |   |   |     |            |
+----------------------+------------+------+---+---+---+-----+------------+
| **Congressional      |            |      |   |   |   |     |            |
| District of Business |            |      |   |   |   |     |            |
| Address**            |            |      |   |   |   |     |            |
+----------------------+------------+------+---+---+---+-----+------------+
| **Congressional      |            |      |   |   |   |     |            |
| District of Primary  |            |      |   |   |   |     |            |
| Service Area**       |            |      |   |   |   |     |            |
+----------------------+------------+------+---+---+---+-----+------------+
| **Zip Code(s) of     |            |      |   |   |   |     |            |
| Primary Service      |            |      |   |   |   |     |            |
| Area(s)**            |            |      |   |   |   |     |            |
|                      |            |      |   |   |   |     |            |
|                      |            |      |   |   |   |     |            |
+----------------------+------------+------+---+---+---+-----+------------+
| **City (ies) and     |            |      |   |   |   |     |            |
| County (ies) of      |            |      |   |   |   |     |            |
| Primary Service      |            |      |   |   |   |     |            |
| Area(s)**            |            |      |   |   |   |     |            |
|                      |            |      |   |   |   |     |            |
|                      |            |      |   |   |   |     |            |
|                      |            |      |   |   |   |     |            |
|                      |            |      |   |   |   |     |            |
|                      |            |      |   |   |   |     |            |
|                      |            |      |   |   |   |     |            |
|                      |            |      |   |   |   |     |            |
|                      |            |      |   |   |   |     |            |
|                      |            |      |   |   |   |     |            |
|                      |            |      |   |   |   |     |            |
|                      |            |      |   |   |   |     |            |
|                      |            |      |   |   |   |     |            |
|                      |            |      |   |   |   |     |            |
|                      |            |      |   |   |   |     |            |
|                      |            |      |   |   |   |     |            |
|                      |            |      |   |   |   |     |            |
+----------------------+------------+------+---+---+---+-----+------------+
| **Total HOPWA        |            |      |   |   |   |     |            |
| Subcontract Amount   |            |      |   |   |   |     |            |
| for this             |            |      |   |   |   |     |            |
| Organization**       |            |      |   |   |   |     |            |
+----------------------+------------+------+---+---+---+-----+------------+

**Part 5: Summary of Project Sponsor Information**

**B. Housing Assistance**

*Note: If the grantee undertakes service delivery activities directly,
complete the respective performance sections (PART 5B-5F) for all
activities conducted by the grantee.*

**1. Tenant-Based Rental Assistance (TBRA)**

Enter the total number of households served and the amount of HOPWA
funds expended by the project sponsor on Tenant-Based Rental Assistance.
Complete a separate chart for each project sponsor.

  ------------ ---------------------------- --------------------- ------------------
  **Housing                                 **Number of           **Total HOPWA
  Assistance                                Households Receiving  Funds Expended
  Categories                                HOPWA Assistance from during Operating
  (TBRA)**                                  Project Sponsor**     Year by Project
                                                                  Sponsor**

  a\.          Tenant-based rental                                   
               assistance (TBRA)                                  

  b\.          Other Rental Assistance (RA)                          
               Programs (if approved in                           
               grant agreement)                                   

  **c.**       **TOTAL Rental Housing                                
               Assistance (total a + b)**                         
  ------------ ---------------------------- --------------------- ------------------

**2. Short-Term Rent, Mortgage and Utility Assistance (STRMU)**

*Enter the total number of households served and the amount of HOPWA
funds expended by this project sponsor on Short-Term Rent, Mortgage and
Utility Assistance. In addition, in Item b, enter the total number of
STRMU assisted households that were homeowners and the amount of
expended by this project sponsor assisting these households. Complete a
separate chart for each project sponsor.*

  ------------ ---------------------------- -------------------------- ------------------
  **Housing                                 **Number of                **Total HOPWA
  Assistance                                [Households]{.underline}   Funds Expended
  Categories                                Receiving HOPWA Assistance during Operating
  (STRMU)**                                 from Project Sponsor**     Year by Project
                                                                       Sponsor**

  a\.          Short-term mortgage, rent                                  
               and/or utility assistance                               

  b\.          Of the above, total STRMU                                  
               assistance to homeowners                                
               (mortgage and/or utility)                               
  ------------ ---------------------------- -------------------------- ------------------

**Part 5: Summary of Project Sponsor Information**

**C. Facility-based Housing Assistance**

Complete the following section for each facility being developed or
supported through HOPWA funds. Complete Charts 1a Project Site
Information and 1b Type of Capital Development Project Units for all
Development Projects. [Charts 2a, 2b and 3 are required for each
facility]{.underline}. In Chart 2a, and 2b, indicate the type of
facility and number of units in each facility. In Chart 3, enter the
total number of households served and the amount funds expended to
support households in each facility. If no expenditures were reported
but the facility was developed with HOPWA funds (subject to ten years of
operation for acquisition, new construction and substantial
rehabilitation costs of stewardship units, or three years for
non-substantial rehabilitation costs) the project sponsor should
complete the "HOPWA Housing Project Certification of Continued Usage
Form" at the end of the report.

**1a. Project Site Information for Capital Development of Projects (For
Capital Development Projects only)**

+---+--------+---------+----------+-----------------------------------+
| * |        | **HOPWA | **N      | **Type of Facility**              |
| * |        | Funds** | on-HOPWA |                                   |
| T |        |         | funds**  | **\[Check [only one]{.underline}  |
| y |        | **Exp   |          | box.\]**                          |
| p |        | ended** | **Ex     |                                   |
| e |        |         | pended** |                                   |
| o |        |         |          |                                   |
| f |        |         |          |                                   |
| D |        |         |          |                                   |
| e |        |         |          |                                   |
| v |        |         |          |                                   |
| e |        |         |          |                                   |
| l |        |         |          |                                   |
| o |        |         |          |                                   |
| p |        |         |          |                                   |
| m |        |         |          |                                   |
| e |        |         |          |                                   |
| n |        |         |          |                                   |
| t |        |         |          |                                   |
| * |        |         |          |                                   |
| * |        |         |          |                                   |
+---+--------+---------+----------+-----------------------------------+
|   |        | **\$**  | **\$**   | Permanent housing                 |
| N |        |         |          |                                   |
| e |        |         |          |                                   |
| w |        |         |          |                                   |
| c |        |         |          |                                   |
| o |        |         |          |                                   |
| n |        |         |          |                                   |
| s |        |         |          |                                   |
| t |        |         |          |                                   |
| r |        |         |          |                                   |
| u |        |         |          |                                   |
| c |        |         |          |                                   |
| t |        |         |          |                                   |
| i |        |         |          |                                   |
| o |        |         |          |                                   |
| n |        |         |          |                                   |
+---+--------+---------+----------+-----------------------------------+
|   |        | **\$**  | **\$**   | Short-term Shelter or             |
| R |        |         |          | Transitional housing              |
| e |        |         |          |                                   |
| h |        |         |          |                                   |
| a |        |         |          |                                   |
| b |        |         |          |                                   |
| i |        |         |          |                                   |
| l |        |         |          |                                   |
| i |        |         |          |                                   |
| t |        |         |          |                                   |
| a |        |         |          |                                   |
| t |        |         |          |                                   |
| i |        |         |          |                                   |
| o |        |         |          |                                   |
| n |        |         |          |                                   |
+---+--------+---------+----------+-----------------------------------+
|   |        | **\$**  | **\$**   | Supportive services only facility |
| A |        |         |          |                                   |
| c |        |         |          |                                   |
| q |        |         |          |                                   |
| u |        |         |          |                                   |
| i |        |         |          |                                   |
| s |        |         |          |                                   |
| i |        |         |          |                                   |
| t |        |         |          |                                   |
| i |        |         |          |                                   |
| o |        |         |          |                                   |
| n |        |         |          |                                   |
+---+--------+---------+----------+-----------------------------------+
| a | Pu     |         |          | Date (mm/dd/yy):                  |
| \ | rchase |         |          |                                   |
| . | /lease |         |          |                                   |
|   | of     |         |          |                                   |
|   | pro    |         |          |                                   |
|   | perty: |         |          |                                   |
+---+--------+---------+----------+-----------------------------------+
| b | Reh    |         |          | Date started:       Date          |
| \ | abilit |         |          | Completed:                        |
| . | ation/ |         |          |                                   |
|   | Constr |         |          |                                   |
|   | uction |         |          |                                   |
|   | Dates: |         |          |                                   |
+---+--------+---------+----------+-----------------------------------+
| c | Ope    |         |          | Date residents began to occupy:   |
| \ | ration |         |          |       Not yet occupied            |
| . | dates: |         |          |                                   |
+---+--------+---------+----------+-----------------------------------+
| d | Date   |         |          | Date started:                     |
| \ | supp   |         |          |                                   |
| . | ortive |         |          | Not yet providing services        |
|   | se     |         |          |                                   |
|   | rvices |         |          |                                   |
|   | began: |         |          |                                   |
+---+--------+---------+----------+-----------------------------------+
| e | Number |         |          | HOPWA-funded units =       Total  |
| \ | of     |         |          | Units =                           |
| . | units  |         |          |                                   |
|   | in the |         |          |                                   |
|   | fac    |         |          |                                   |
|   | ility: |         |          |                                   |
+---+--------+---------+----------+-----------------------------------+
| f | Is a   |         |          | Yes No\                           |
| \ | w      |         |          | *If yes, number of participants   |
| . | aiting |         |          | on the list at the end of         |
|   | list   |         |          | operating year*                   |
|   | main   |         |          |                                   |
|   | tained |         |          |                                   |
|   | for    |         |          |                                   |
|   | the    |         |          |                                   |
|   | fac    |         |          |                                   |
|   | ility? |         |          |                                   |
+---+--------+---------+----------+-----------------------------------+
| g | What   |         |          |                                   |
| \ | is the |         |          |                                   |
| . | a      |         |          |                                   |
|   | ddress |         |          |                                   |
|   | of the |         |          |                                   |
|   | fa     |         |          |                                   |
|   | cility |         |          |                                   |
|   | (if    |         |          |                                   |
|   | dif    |         |          |                                   |
|   | ferent |         |          |                                   |
|   | from   |         |          |                                   |
|   | bu     |         |          |                                   |
|   | siness |         |          |                                   |
|   | add    |         |          |                                   |
|   | ress)? |         |          |                                   |
+---+--------+---------+----------+-----------------------------------+
| h | Is the |         |          | *Yes, protect information; do not |
| \ | a      |         |          | publish list.*                    |
| . | ddress |         |          |                                   |
|   | of the |         |          | *No, can be made available to the |
|   | p      |         |          | public.*                          |
|   | roject |         |          |                                   |
|   | site   |         |          |                                   |
|   | c      |         |          |                                   |
|   | onfide |         |          |                                   |
|   | ntial? |         |          |                                   |
+---+--------+---------+----------+-----------------------------------+

**1b. Type of Capital Development Project Units (For Capital Development
Projects only)**

For units entered above (1 a) please list the number of HOPWA units that
fulfill the following criteria.

+-----------+---------+--------+---------+-----------+---------------+
|           | Des     | Desi   | Ener    | 504       | Years of      |
|           | ignated | gnated | gy-Star | A         | affordability |
|           | for the | for    | Co      | ccessible |               |
|           | chro    | assist | mpliant |           | (IN YEARS)    |
|           | nically | the    |         |           |               |
|           | h       | ho     |         |           |               |
|           | omeless | meless |         |           |               |
+-----------+---------+--------+---------+-----------+---------------+
| Rental    |         |        |         |           |               |
| units     |         |        |         |           |               |
| co        |         |        |         |           |               |
| nstructed |         |        |         |           |               |
| (new)     |         |        |         |           |               |
| and/or    |         |        |         |           |               |
| acquired  |         |        |         |           |               |
| with or   |         |        |         |           |               |
| without   |         |        |         |           |               |
| rehab     |         |        |         |           |               |
+-----------+---------+--------+---------+-----------+---------------+
| Rental    |         |        |         |           |               |
| units     |         |        |         |           |               |
| rehabbed  |         |        |         |           |               |
+-----------+---------+--------+---------+-----------+---------------+
| Home      |         |        |         |           |               |
| ownership |         |        |         |           |               |
| units     |         |        |         |           |               |
| co        |         |        |         |           |               |
| nstructed |         |        |         |           |               |
| (if       |         |        |         |           |               |
| approved) |         |        |         |           |               |
+-----------+---------+--------+---------+-----------+---------------+

**2. Units assisted in types of housing facility/units leased by
sponsor**

Indicate the type and number of housing units in the facility,
categorized by the number of bedrooms per unit. *Note: The number units
may not equal the total number of households served. Please complete
this page for each housing facility assisted.*

**a. Check one only**.

  -----------------------------------------------------------------------
  Permanent Supportive Housing Facility/Units

  Short-term Shelter or Transitional Supportive Housing Facility/Units
  -----------------------------------------------------------------------

**b. Type of Facility**

  ----------- ------------------------ ------------- -------- ----------- -------- -------- ------------
  **Type of                            **Total                                              
  housing                              Number of                                            
  facility                             Units                                                
  operated by                          Operated in                                          
  the project                          the Operating                                        
  sponsor**                            Year\                                                
                                       Categorized                                          
                                       by the Number                                        
                                       of Bedrooms                                          
                                       per Units**                                          

                                       **SRO/0       **1      **2bdrm**   **3      **4      **5+bdrm**
                                       bdrm**        bdrm**               bdrm**   bdrm**   

  a\.         Single room occupancy                                                         
              dwelling                                                                      

  b\.         Community residence                                                              

  c\.         Project-based rental                                                             
              assistance units or                                                           
              leased units                                                                  

  d\.         Other housing facility.                                                          
              Specify:                                                                      
  ----------- ------------------------ ------------- -------- ----------- -------- -------- ------------

**3. Housing Expenditures**

Enter the total number of households served and the amount of HOPWA
funds expended by the project sponsor on subsidies for housing involving
the use of facilities, master leased units, or other scattered site
units leased by the organization.

  -------------- ------------------------ ------------------------- -----------------
  **Housing                               **Number of Households    **Total HOPWA
  Assistance                              Served with HOPWA         Funds Expended
  Categories**                            Assistance from Project   during Operating
                                          Sponsor**                 Year by Project
                                                                    Sponsor**

  a\.            Leasing Costs                                         

  b\.            Operating Costs                                       

  c\.            Project-Based Rental                                  
                 Assistance (PBRA) or                               
                 other leased units                                 

  d\.            Other Activity (if                                    
                 approved in grant                                  
                 agreement). Specify:                               

  e\.            **Adjustment to                                    
                 eliminate duplication                              
                 (subtract)**                                       

  **f.**         **TOTAL Facility-Based                                
                 Housing Assistance**                               
  -------------- ------------------------ ------------------------- -----------------

**Part 5: Summary of Project Sponsor Information**

**D. Supportive Services**

Report on the use of HOPWA funds for supportive services. In Table 1, if
the project sponsor provides HOPWA funded housing and services to
clients, check 1a. Alternatively, if the project sponsor provides HOPWA
funded supportive services to grantees serving households who have other
housing arrangements, check 1b. In Table 2, rows 1 through 27, provide
the (unduplicated) total of all households and expenditures for each
type of supportive services, housing placement, and grant administration
and other activities provided by the project sponsor. Use a separate
page for each project sponsor.

**1. Supportive Service by type of Project Sponsor (Check one only)**

  ---------------------------------------------------------------- ------
  a\. Supportive Services are provided by project sponsors also    
  delivering HOPWA housing assistance                              

  or                                                               

  b\. Supportive Services by project sponsors serving households   
  with other housing arrangements                                  
  ---------------------------------------------------------------- ------

**2. Listing of Supportive Services provided by Project Sponsor Agency**

+---+-------------------------+--------------------+-------------------+
| * |                         | **Number of        | **Amount of HOPWA |
| * |                         | Households         | Funds Expended**  |
| S |                         | Receiving HOPWA    |                   |
| u |                         | Assistance**       |                   |
| p |                         |                    |                   |
| p |                         |                    |                   |
| o |                         |                    |                   |
| r |                         |                    |                   |
| t |                         |                    |                   |
| i |                         |                    |                   |
| v |                         |                    |                   |
| e |                         |                    |                   |
| S |                         |                    |                   |
| e |                         |                    |                   |
| r |                         |                    |                   |
| v |                         |                    |                   |
| i |                         |                    |                   |
| c |                         |                    |                   |
| e |                         |                    |                   |
| s |                         |                    |                   |
| \ |                         |                    |                   |
| * |                         |                    |                   |
| * |                         |                    |                   |
+---+-------------------------+--------------------+-------------------+
| 1 | Adult day care and      |                    |                   |
| \ | personal assistance     |                    |                   |
| . |                         |                    |                   |
+---+-------------------------+--------------------+-------------------+
| 2 | Alcohol and drug abuse  |                    |                   |
| \ | services                |                    |                   |
| . |                         |                    |                   |
+---+-------------------------+--------------------+-------------------+
| 3 | Case management/client  |                    |                   |
| \ | advocacy/ access to     |                    |                   |
| . | benefits & services     |                    |                   |
+---+-------------------------+--------------------+-------------------+
| 4 | Child care and other    |                    |                   |
| \ | child services          |                    |                   |
| . |                         |                    |                   |
+---+-------------------------+--------------------+-------------------+
| 5 | Education               |                    |                   |
| \ |                         |                    |                   |
| . |                         |                    |                   |
+---+-------------------------+--------------------+-------------------+
| 6 | Employment assistance   |                    |                   |
| \ | and training            |                    |                   |
| . |                         |                    |                   |
+---+-------------------------+--------------------+-------------------+
| 7 | H                       |                    |                   |
| \ | ealth/medical/intensive |                    |                   |
| . | care services, if       |                    |                   |
|   | approved                |                    |                   |
|   |                         |                    |                   |
|   | Note: Client records    |                    |                   |
|   | must conform with 24    |                    |                   |
|   | CFR §574.310            |                    |                   |
+---+-------------------------+--------------------+-------------------+
| 8 | Legal services          |                    |                   |
| \ |                         |                    |                   |
| . |                         |                    |                   |
+---+-------------------------+--------------------+-------------------+
| 9 | Life skills management  |                    |                   |
| \ | (outside of case        |                    |                   |
| . | management)             |                    |                   |
+---+-------------------------+--------------------+-------------------+
| 1 | Meals/nutritional       |                    |                   |
| 0 | services                |                    |                   |
| \ |                         |                    |                   |
| . |                         |                    |                   |
+---+-------------------------+--------------------+-------------------+
| 1 | Mental health services  |                    |                   |
| 1 |                         |                    |                   |
| \ |                         |                    |                   |
| . |                         |                    |                   |
+---+-------------------------+--------------------+-------------------+
| 1 | Outreach                |                    |                   |
| 2 |                         |                    |                   |
| \ |                         |                    |                   |
| . |                         |                    |                   |
+---+-------------------------+--------------------+-------------------+
| 1 | Transportation          |                    |                   |
| 3 |                         |                    |                   |
| \ |                         |                    |                   |
| . |                         |                    |                   |
+---+-------------------------+--------------------+-------------------+
| 1 | Other Activity (if      |                    |                   |
| 4 | approved in grant       |                    |                   |
| \ | agreement). Specify:    |                    |                   |
| . |                         |                    |                   |
+---+-------------------------+--------------------+-------------------+
| 1 | **Adjustment for        |                    |                   |
| 5 | Duplication             |                    |                   |
| \ | (subtract)**            |                    |                   |
| . |                         |                    |                   |
+---+-------------------------+--------------------+-------------------+
| 1 | **TOTAL Households      |                    |                   |
| 6 | receiving Supportive    |                    |                   |
| \ | Services                |                    |                   |
| . | (unduplicated)**        |                    |                   |
+---+-------------------------+--------------------+-------------------+
|   | **Housing Placement     | **Number of        | **Amount of HOPWA |
|   | Assistance Categories** | Households         | funds Expended**  |
|   |                         | Receiving HOPWA    |                   |
|   |                         | Assistance**       |                   |
+---+-------------------------+--------------------+-------------------+
| 1 | Housing Information     |                    |                   |
| 7 | Services                |                    |                   |
| \ |                         |                    |                   |
| . |                         |                    |                   |
+---+-------------------------+--------------------+-------------------+
| 1 | Permanent Housing       |                    |                   |
| 8 | Placement Services      |                    |                   |
| \ |                         |                    |                   |
| . |                         |                    |                   |
+---+-------------------------+--------------------+-------------------+
| 1 | **Adjustment for        |                    |                   |
| 9 | duplication             |                    |                   |
| \ | (subtract)**            |                    |                   |
| . |                         |                    |                   |
+---+-------------------------+--------------------+-------------------+
| * | **TOTAL Housing         |                    |                   |
| * | Placement Assistance    |                    |                   |
| 2 | (unduplicated, sum of   |                    |                   |
| 0 | items 17 + 18)**        |                    |                   |
| . |                         |                    |                   |
| * |                         |                    |                   |
| * |                         |                    |                   |
+---+-------------------------+--------------------+-------------------+
|   | **Grant Administration  | **Number of        | **Amount of HOPWA |
|   | and Other Activities**  | Households         | funds Expended**  |
|   |                         | Receiving HOPWA    |                   |
|   |                         | Assistance**       |                   |
+---+-------------------------+--------------------+-------------------+
| 2 | Resource Identification |                    |                   |
| 1 | to establish,           |                    |                   |
| \ | coordinate, and develop |                    |                   |
| . | housing assistance      |                    |                   |
|   | resources               |                    |                   |
+---+-------------------------+--------------------+-------------------+
| 2 | Technical Assistance to |                    |                   |
| 2 | Community Residences    |                    |                   |
| \ |                         |                    |                   |
| . |                         |                    |                   |
+---+-------------------------+--------------------+-------------------+
| 2 | Project                 |                    |                   |
| 3 | Outcomes/Program        |                    |                   |
| \ | Evaluation (if          |                    |                   |
| . | approved)               |                    |                   |
+---+-------------------------+--------------------+-------------------+
| 2 | Project Sponsor         |                    |                   |
| 4 | Administration          |                    |                   |
| \ |                         |                    |                   |
| . | (maximum 7% of portion  |                    |                   |
|   | of HOPWA grant awarded) |                    |                   |
+---+-------------------------+--------------------+-------------------+
| 2 | Other Activity (if      |                    |                   |
| 5 | approved in grant       |                    |                   |
| \ | agreement) Specify:     |                    |                   |
| . |                         |                    |                   |
+---+-------------------------+--------------------+-------------------+
| * | **TOTAL Administration  |                    |                   |
| * | and Other Activities**  |                    |                   |
| 2 |                         |                    |                   |
| 6 |                         |                    |                   |
| . |                         |                    |                   |
| * |                         |                    |                   |
| * |                         |                    |                   |
+---+-------------------------+--------------------+-------------------+
| * | **TOTAL Expenditures    |                    |                   |
| * | (sum of items 16 + 20   |                    |                   |
| 2 | +26)**                  |                    |                   |
| 7 |                         |                    |                   |
| . |                         |                    |                   |
| * |                         |                    |                   |
| * |                         |                    |                   |
+---+-------------------------+--------------------+-------------------+

**Part 5: Summary of Project Sponsor Information**

**E. Certification of Continued Usage for HOPWA Facility-Based
Stewardship Units (ONLY)**

Grantees that use HOPWA funding for new construction, acquisition, or
substantial rehabilitation are required to operate their facilities for
HOPWA eligible individuals for at least ten years. If non-substantial
rehabilitation funds were used they are required to operate for at least
three years. Stewardship begins once the facility is put into operation.
This Annual Certification of Continued HOPWA Project Operations is to be
used in place of other sections of the APR, in the case that no
additional HOPWA funds were expended in this operating year at this
facility that had been acquired, rehabilitated or constructed and
developed in part with HOPWA funds.

1\. General information

+--------------------------------------+-------------------------------+
| HUD Grant Number(s)                  | **Operating Year for this     |
|                                      | report**                      |
|                                      |                               |
|                                      | ***From (mm/dd/yy) to         |
|                                      | (mm/dd/yy)*** Final Yr        |
|                                      |                               |
|                                      | Yr 1; Yr 2; Yr 3; Yr 4; Yr 5; |
|                                      | Yr 6;                         |
|                                      |                               |
|                                      | Yr 7; Yr 8; Yr 9; Yr 10;      |
+--------------------------------------+-------------------------------+
| Grantee Name                         | Date Facility Began           |
|                                      | Operations                    |
|                                      |                               |
|                                      |                               |
+--------------------------------------+-------------------------------+

**2. Number of Units and Leveraging**

  ------------------------- --------------------- ------------------------
  **Housing Assistance**    **Number of Units     **Amount of Leveraging
                            Receiving Housing     from Other Sources Used
                            Assistance with HOPWA during the Operating
                            funds**               Year**

  Stewardship units                                    
  (developed with HOPWA                           
  funds but no current                            
  operations or other HOPWA                       
  costs) subject to 3- or                         
  10- year use periods                            
  ------------------------- --------------------- ------------------------

3\. Details of Project Site

+------------------------+---------------------------------------------+
| Project Sites: Name of |                                             |
| HOPWA-funded project   |                                             |
+------------------------+---------------------------------------------+
| Site Information:      |                                             |
| Project Zip Code(s)    |                                             |
| and Congressional      |                                             |
| District(s)            |                                             |
+------------------------+---------------------------------------------+
| Is the address of the  | *Yes, protect information; do not list.*    |
| project site           |                                             |
| confidential?          | *Not confidential; information can be made  |
|                        | available to the public.*                   |
+------------------------+---------------------------------------------+
| If the site is         |                                             |
| available to the       |                                             |
| public, please provide |                                             |
| the contact            |                                             |
| information, phone,    |                                             |
| email                  |                                             |
| address/location, if   |                                             |
| business address is    |                                             |
| different from         |                                             |
| facility address.      |                                             |
+------------------------+---------------------------------------------+

I certify that the facility that received assistance for acquisition,
rehabilitation, or new construction from the Housing Opportunities for
Persons with AIDS Program has operated as a facility to assist
HOPWA-eligible persons from the date shown**.** I also certify that the
grant is still serving the planned number of HOPWA-eligible households
at this facility through other resources and all the requirements of the
grant agreement are being satisfied.

+-----------------------------------+-----------------------------------+
| *I hereby certify that all the    |                                   |
| information stated herein, as     |                                   |
| well as any information provided  |                                   |
| in the accompaniment herewith, is |                                   |
| true and accurate.***\            |                                   |
| **                                |                                   |
+-----------------------------------+-----------------------------------+
| **Name & Title of Authorized      | **Signature & Date (mm/dd/yy)**   |
| Official**                        |                                   |
|                                   |                                   |
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| **Name & Title of Contact at      | **Contact Phone (include area     |
| Grantee Agency\                   | code)**                           |
| ***(person who can answer         |                                   |
| questions about the report and    |                                   |
| program)*                         |                                   |
|                                   |                                   |
|                                   |                                   |
+-----------------------------------+-----------------------------------+

**Part 6: Worksheet - Determining HOPWA Outcomes and Connections with
HMIS**

**1.** This Chart is designed to help you assess program results based
on the information reported in Part 4.

+----------+------------+-------------+------------+--------+---------+
| **P      | **Stable   | **Temporary |            | **Un   | **Life  |
| ermanent | Housing**  | Housing**   |            | stable | Event** |
| Housing  |            |             |            | Ar     |         |
| Assi     | (#         | \(2\)       |            | rangem | \(9\)   |
| stance** | remaining  |             |            | ents** |         |
|          | in program |             |            |        |         |
|          | plus       |             |            | (1+    |         |
|          | 3+4+5+6=#) |             |            | 7+8=#) |         |
+----------+------------+-------------+------------+--------+---------+
| Tena     |            |             |            |        |         |
| nt-based |            |             |            |        |         |
| Rental   |            |             |            |        |         |
| As       |            |             |            |        |         |
| sistance |            |             |            |        |         |
| (TBRA)   |            |             |            |        |         |
+----------+------------+-------------+------------+--------+---------+
| P        |            |             |            |        |         |
| ermanent |            |             |            |        |         |
| Facili   |            |             |            |        |         |
| ty-Based |            |             |            |        |         |
| Housing  |            |             |            |        |         |
| Assistan |            |             |            |        |         |
| ce/Units |            |             |            |        |         |
+----------+------------+-------------+------------+--------+---------+
| Transit  |            |             |            |        |         |
| ional/Sh |            |             |            |        |         |
| ort-term |            |             |            |        |         |
| Facili   |            |             |            |        |         |
| ty-Based |            |             |            |        |         |
| Housing  |            |             |            |        |         |
| Assistan |            |             |            |        |         |
| ce/Units |            |             |            |        |         |
+----------+------------+-------------+------------+--------+---------+
| Total    |            |             |            |        |         |
| P        |            |             |            |        |         |
| ermanent |            |             |            |        |         |
| HOPWA    |            |             |            |        |         |
| Housing  |            |             |            |        |         |
| As       |            |             |            |        |         |
| sistance |            |             |            |        |         |
+----------+------------+-------------+------------+--------+---------+
|          |            |             |            |        |         |
+----------+------------+-------------+------------+--------+---------+
| *        | **Stable   | **          |            | **Un   | **Life  |
| *Reduced | /Permanent | Temporarily |            | stable | E       |
| Risk of  | Housing**  | Stable,     |            | Ar     | vents** |
| Homel    |            | with        |            | rangem |         |
| essness: |            | Reduced     |            | ents** |         |
| Sh       |            | Risk of     |            |        |         |
| ort-Term |            | Hom         |            |        |         |
| Assi     |            | elessness** |            |        |         |
| stance** |            |             |            |        |         |
+----------+------------+-------------+------------+--------+---------+
| Sh       |            |             |            |        |         |
| ort-term |            |             |            |        |         |
| Rent,    |            |             |            |        |         |
| M        |            |             |            |        |         |
| ortgage, |            |             |            |        |         |
| and      |            |             |            |        |         |
| Utility  |            |             |            |        |         |
| As       |            |             |            |        |         |
| sistance |            |             |            |        |         |
| (STRMU)  |            |             |            |        |         |
+----------+------------+-------------+------------+--------+---------+
| Total    |            |             |            |        |         |
| HOPWA    |            |             |            |        |         |
| Housing  |            |             |            |        |         |
| As       |            |             |            |        |         |
| sistance |            |             |            |        |         |
+----------+------------+-------------+------------+--------+---------+

**Background on HOPWA Housing Stability Codes**

**Stable Permanent Housing/Ongoing Participation**

3 = Private Housing in the private rental or home ownership market
(without known subsidy, including permanent placement with families or
other self sufficient arrangements) with reasonable expectation that
additional support is not needed.

4 = Other HOPWA-funded housing assistance (not STRMU), e.g. TBRA or
Facility-Based Assistance.

5 = Other subsidized house or apartment (non-HOPWA sources, e.g.,
Section 8, HOME, Public Housing).

6 = Institutional setting with greater support and continued residence
expected (e.g., residential or long-term care facility).

**Temporary Housing**

2 = Temporary housing: moved in with family/friends or other short-term
arrangement, such as Ryan White subsidy, transitional housing for
homeless, or temporary placement in institution (e.g., hospital,
psychiatric hospital or other psychiatric facility, substance abuse
treatment facility or detox center).

**Unstable Arrangements**

1 = Emergency shelter or no housing destination such as places not meant
for habitation (e.g., a vehicle, an abandoned building, bus/train/subway
station, or anywhere outside).

7 = Jail /Prison.

8 = Disconnected or disappeared from project support, unknown
destination or no assessments of housing needs were undertaken.

Life Event

9 = Death, i.e., remained in housing until death. This characteristic is
not factored into the housing stability equation.

**Tenant-based Rental Assistance**: [Stable Housing]{.underline} is the
sum of the number of households that (i) remain in the housing and (ii)
those that left the assistance as reported under: 3, 4, 5, and 6.
[Temporary Housing]{.underline} is the number of households that
accessed assistance, and left their current housing for a non-permanent
housing arrangement, as reported under item 2. [Unstable
Situations]{.underline} is the sum of numbers reported under items: 1,
7, and 8.

**Permanent Facility-Based Housing Assistance**: [Stable
Housing]{.underline} is the sum of the number of households that (i)
remain in the housing and (ii) those that left the assistance as shown
as items: 3, 4, 5, and 6. [Temporary Housing]{.underline} is the number
of households that accessed assistance, and left their current housing
for a non-permanent housing arrangement, as reported under item 2.
[Unstable Situations]{.underline} is the sum of numbers reported under
items: 1, 7, and 8.

**Transitional/Short-Term Facility-Based Housing Assistance:** [Stable
Housing]{.underline} is the sum of the number of households that (i)
continue in the residences (ii) those that left the assistance as shown
as items: 3, 4, 5, and 6. [Other Temporary Housing]{.underline} is the
number of households that accessed assistance, and left their current
housing for a non-permanent housing arrangement, as reported under item
2. [Unstable Situations]{.underline} is the sum of numbers reported
under items: 1, 7, and 8.

**Tenure Assessment**. A baseline of households in
transitional/short-term facilities for assessment purposes, indicate the
number of households whose tenure exceeded 24 months.

**STRMU Assistance**: [Stable Housing]{.underline} is the sum of the
number of households that accessed assistance for some portion of the
permitted 21-week period and there is reasonable expectation that
additional support is not needed in order to maintain permanent housing
living situation (as this is a time-limited form of housing support) as
reported under housing status: Maintain Private Housing with subsidy;
Other Private with Subsidy; Other HOPWA support; Other Housing Subsidy;
and Institution. [Temporarily Stable, with Reduced Risk of
Homelessness]{.underline} is the sum of the number of households that
accessed assistance for some portion of the permitted 21-week period or
left their current housing arrangement for a transitional facility or
other temporary/non-permanent housing arrangement and there is
reasonable expectation additional support will be needed to maintain
housing arrangements in the next year, as reported under housing status:
Likely to maintain current housing arrangements, with additional STRMU
assistance; Transitional Facilities/Short-term; and
Temporary/Non-Permanent Housing arrangements [Unstable
Situation]{.underline} is the sum of number of households reported under
housing status: Emergency Shelter; Jail/Prison; and Disconnected.

**Background information on Universal Data Elements for Homeless
Management Information Systems (HMIS), may be used by HOPWA projects to
help coordinate assistance (Optional Format and edits \*).**

+--------------------------+----------------------+--------------------+
| Data Element             | Response Category    |                    |
+--------------------------+----------------------+--------------------+
| 2.1 Name                 | First Name Middle    |                    |
|                          | Name Last Name       |                    |
|                          | Suffix               |                    |
+--------------------------+----------------------+--------------------+
| Current Name             |                      |                    |
+--------------------------+----------------------+--------------------+
| Other Name Used to       |                      |                    |
| Receive Services         |                      |                    |
| Previously               |                      |                    |
+--------------------------+----------------------+--------------------+
| 2.2 Social Security      | 1=Full SSN Reported  |                    |
| Number                   |                      |                    |
|                          | 2=Partial SSN        |                    |
|                          | Reported             |                    |
|                          |                      |                    |
|                          | 8=Don't Know or      |                    |
|                          | Don't Have SSN       |                    |
|                          |                      |                    |
|                          | 9=Refused            |                    |
+--------------------------+----------------------+--------------------+
| 2.3 Date of Birth        | Month/Day/Year:      |                    |
|                          | \_\_/-\_\_/\_\_\_\_  |                    |
+--------------------------+----------------------+--------------------+
| 2.4 Ethnicity and Race   |                      |                    |
+--------------------------+----------------------+--------------------+
| Ethnicity                | 0                    |                    |
|                          | =non-Hispanic/Latino |                    |
|                          |                      |                    |
|                          | 1=Hispanic/Latino    |                    |
+--------------------------+----------------------+--------------------+
| Race *(\* items 6-10     | 1=American Indian or | *6= American       |
| added to HMIS list)*     | Alaskan Native       | Indian or Alaskan  |
|                          |                      | Native and White*  |
|                          | 2=Asian              |                    |
|                          |                      | *7=Asian and       |
|                          | 3=Black or           | White*             |
|                          | African-American     |                    |
|                          |                      | *8=Black or        |
|                          | 4=Native Hawaiian or | African-American   |
|                          | Other Pacific        | and White*         |
|                          | Islander             |                    |
|                          |                      | *9=American Indian |
|                          | 5=White              | or Alaskan Native  |
|                          |                      | and Black or       |
|                          |                      | African-American*  |
|                          |                      |                    |
|                          |                      | *10=Other          |
|                          |                      | Multi-Racial*      |
+--------------------------+----------------------+--------------------+
| 2.5 Gender               | 0=Female             |                    |
|                          |                      |                    |
|                          | 1=Male               |                    |
+--------------------------+----------------------+--------------------+
| 2.6 Veteran Status       | 0=No 1=Yes           |                    |
|                          |                      |                    |
|                          | 8=Don't Know         |                    |
|                          | 9=Refused            |                    |
+--------------------------+----------------------+--------------------+
| 2.7 Disability Status    | 0=No 1=Yes           |                    |
|                          |                      |                    |
|                          | 8=Don't Know         |                    |
|                          | 9=Refused            |                    |
+--------------------------+----------------------+--------------------+
| 2.8 Residence Prior to   | 1=Emergency shelter  |                    |
| Program Entry            |                      |                    |
|                          | 2=Transitional       |                    |
|                          | housing for homeless |                    |
|                          | persons              |                    |
|                          |                      |                    |
|                          | 3=Permanent housing  |                    |
|                          | for formerly         |                    |
|                          | homeless persons     |                    |
|                          | (such as Shelter     |                    |
|                          | Plus Care, SHP, or   |                    |
|                          | SRO Mod Rehab)       |                    |
|                          |                      |                    |
|                          | 4=Psychiatric        |                    |
|                          | hospital or other    |                    |
|                          | psychiatric facility |                    |
|                          |                      |                    |
|                          | 5=Substance abuse    |                    |
|                          | treatment facility   |                    |
|                          | or detox center      |                    |
|                          |                      |                    |
|                          | 6=Hospital           |                    |
|                          | (non-psychiatric     |                    |
|                          | facility)            |                    |
|                          |                      |                    |
|                          | 7=Jail, prison or    |                    |
|                          | juvenile detention   |                    |
|                          | facility             |                    |
|                          |                      |                    |
|                          | 10=Rented room,      |                    |
|                          | apartment, or house  |                    |
|                          |                      |                    |
|                          | 11=House you own     |                    |
|                          |                      |                    |
|                          | 12=Staying or living |                    |
|                          | in someone else's    |                    |
|                          | (family and friends) |                    |
|                          | room, apartment, or  |                    |
|                          | house                |                    |
|                          |                      |                    |
|                          | 13=Hotel or motel    |                    |
|                          | paid for without     |                    |
|                          | emergency shelter    |                    |
|                          | voucher              |                    |
|                          |                      |                    |
|                          | 14=Foster care home  |                    |
|                          | or foster care group |                    |
|                          | home                 |                    |
|                          |                      |                    |
|                          | 15=Place not meant   |                    |
|                          | for habitation       |                    |
|                          | (e.g., a vehicle, an |                    |
|                          | abandoned building,  |                    |
|                          | bus/train/subway     |                    |
|                          | station/airport, or  |                    |
|                          | anywhere outside)    |                    |
|                          |                      |                    |
|                          | 16=Other             |                    |
|                          |                      |                    |
|                          | 8=Don't Know         |                    |
|                          |                      |                    |
|                          | 9=Refused            |                    |
+--------------------------+----------------------+--------------------+
| Length of Stay in        | 1=One week or less   |                    |
| Previous Place           |                      |                    |
|                          | 2=More than one      |                    |
|                          | week, but less than  |                    |
|                          | one month            |                    |
|                          |                      |                    |
|                          | 3=One to three       |                    |
|                          | months               |                    |
|                          |                      |                    |
|                          | 4=More than three    |                    |
|                          | months, but less     |                    |
|                          | than one year        |                    |
|                          |                      |                    |
|                          | 5=One year or longer |                    |
+--------------------------+----------------------+--------------------+
| 2.9 Zip Code of Last     | 1=Full Zip Code      |                    |
| Permanent Address        | Recorded             |                    |
|                          |                      |                    |
|                          | 8=Don't Know         |                    |
|                          |                      |                    |
|                          | 9=Refused            |                    |
+--------------------------+----------------------+--------------------+
| 2.10 Program Entry Date  | Month/Day/Year:      |                    |
|                          | \_\_/\_\_/\_\_\_\_   |                    |
+--------------------------+----------------------+--------------------+
| 2.11 Program Exit Date   | Month/Day/Year:      |                    |
|                          | \_\_/\_\_/\_\_\_\_   |                    |
+--------------------------+----------------------+--------------------+
| 2.12 Unique Person       | A PIN must be        |                    |
| Identification Number    | created, but there   |                    |
|                          | is no required       |                    |
|                          | format as long as    |                    |
|                          | there is a single    |                    |
|                          | unique PIN for every |                    |
|                          | client served and it |                    |
|                          | contains no          |                    |
|                          | personally           |                    |
|                          | identifying          |                    |
|                          | information.         |                    |
+--------------------------+----------------------+--------------------+
| 2.14 Household           | A Household ID       |                    |
| Identification Number    | number must be       |                    |
|                          | created, but there   |                    |
|                          | is no required       |                    |
|                          | format as long as    |                    |
|                          | the number allows    |                    |
|                          | identification of    |                    |
|                          | clients that receive |                    |
|                          | services as a        |                    |
|                          | household.           |                    |
+--------------------------+----------------------+--------------------+

**Information on HOPWA Program Specific Data Elements in HMIS.**

+----------------------------+--------------------+--------------------+
| Data Element               | Response Category  |                    |
+----------------------------+--------------------+--------------------+
| 3.1 Income and Source      | 1=Earned Income    |                    |
|                            |                    |                    |
|                            | 2=Unemployed       |                    |
|                            | Insurance          |                    |
|                            |                    |                    |
|                            | 3=Supplemental     |                    |
|                            | Security Income or |                    |
|                            | SSI                |                    |
|                            |                    |                    |
|                            | 4=Social Security  |                    |
|                            | Disability Income  |                    |
|                            | (SSDI)             |                    |
|                            |                    |                    |
|                            | 5=A veteran's      |                    |
|                            | disability payment |                    |
|                            |                    |                    |
|                            | 6=Private          |                    |
|                            | disability         |                    |
|                            | insurance          |                    |
|                            |                    |                    |
|                            | 7=Worker's         |                    |
|                            | compensation       |                    |
|                            |                    |                    |
|                            | 8=Temporary        |                    |
|                            | Assistance for     |                    |
|                            | Needy Families     |                    |
|                            | (TANF) (or use     |                    |
|                            | local program      |                    |
|                            | name)              |                    |
|                            |                    |                    |
|                            | 9=General          |                    |
|                            | Assistance (GA)    |                    |
|                            | (or use local      |                    |
|                            | program name)      |                    |
|                            |                    |                    |
|                            | 10=Retirement      |                    |
|                            | income from Social |                    |
|                            | Security           |                    |
|                            |                    |                    |
|                            | 11=Veteran's       |                    |
|                            | pension            |                    |
|                            |                    |                    |
|                            | 12=Pension from a  |                    |
|                            | former job         |                    |
|                            |                    |                    |
|                            | 13=Child support   |                    |
|                            |                    |                    |
|                            | 14=Alimony or      |                    |
|                            | other spousal      |                    |
|                            | support            |                    |
|                            |                    |                    |
|                            | 15=Other source    |                    |
|                            |                    |                    |
|                            | 16=No financial    |                    |
|                            | resources          |                    |
+----------------------------+--------------------+--------------------+
| Total Month Income         | \$\_\_\_\_.00      |                    |
+----------------------------+--------------------+--------------------+
| 3.2 Source of Non-Cash     | 1=Food stamps or   |                    |
| Benefits                   | money for food on  |                    |
|                            | a benefits card    |                    |
|                            |                    |                    |
|                            | 2=MEDICAID health  |                    |
|                            | insurance program  |                    |
|                            | (or use local      |                    |
|                            | name)              |                    |
|                            |                    |                    |
|                            | 3=MEDICARE health  |                    |
|                            | insurance program  |                    |
|                            | (or use local      |                    |
|                            | name)              |                    |
|                            |                    |                    |
|                            | 4=State Children's |                    |
|                            | Health Insurance   |                    |
|                            | Program (or use    |                    |
|                            | local name)        |                    |
|                            |                    |                    |
|                            | 5=Special          |                    |
|                            | Supplemental       |                    |
|                            | Nutrition Program  |                    |
|                            | for Women,         |                    |
|                            | Infants, and       |                    |
|                            | Children (WIC)     |                    |
|                            |                    |                    |
|                            | 6=Veteran's        |                    |
|                            | Administration     |                    |
|                            | (VA) Medical       |                    |
|                            | Services           |                    |
|                            |                    |                    |
|                            | 7=TANF Child Care  |                    |
|                            | services (or use   |                    |
|                            | local name)        |                    |
|                            |                    |                    |
|                            | 8=TANF             |                    |
|                            | transportation     |                    |
|                            | services (or use   |                    |
|                            | local name)        |                    |
|                            |                    |                    |
|                            | 9=Other            |                    |
|                            | TANF-funded        |                    |
|                            | services (or use   |                    |
|                            | local name)        |                    |
|                            |                    |                    |
|                            | 10=Section 8,      |                    |
|                            | public housing, or |                    |
|                            | other rental       |                    |
|                            | assistance         |                    |
|                            |                    |                    |
|                            | 11=Other source    |                    |
+----------------------------+--------------------+--------------------+
| 3.5 HIV/AIDS Status        | 0=No               |                    |
|                            |                    |                    |
|                            | 1=Yes              |                    |
+----------------------------+--------------------+--------------------+
| 3.8 Services Received      |                    |                    |
+----------------------------+--------------------+--------------------+
| Date of service            | Month/Day/Year:    |                    |
|                            | \_\_/\_\_/\_\_\_\_ |                    |
+----------------------------+--------------------+--------------------+
| Service type               | 1=Food             | 1                  |
|                            |                    | 0=HIV/AIDS-related |
|                            | 2=Housing          | services           |
|                            | placement          |                    |
|                            |                    | 11=Mental health   |
|                            | 3=Material goods   | counseling         |
|                            |                    |                    |
|                            | 4=Temporary        | 12=Substance abuse |
|                            | financial aid      | services           |
|                            |                    |                    |
|                            | 5=Transportation   | 13=Employment      |
|                            |                    |                    |
|                            | 6=Consumer         | 14=Case/care       |
|                            | assistance and     | management         |
|                            | protection         |                    |
|                            |                    | 15=Day care        |
|                            | 7=Criminal         |                    |
|                            | justice/legal      | 16=Personal        |
|                            | services           | enrichment         |
|                            |                    |                    |
|                            | 8=Education        | 17=Outreach        |
|                            |                    |                    |
|                            | 9=Health care      | 18=Other           |
+----------------------------+--------------------+--------------------+

+----------------------------+--------------------+--------------------+
| Data Element               | Response Category  |                    |
+----------------------------+--------------------+--------------------+
| 3.9 Housing Status end of  |                    |                    |
| operating year or          |                    |                    |
| Destination                |                    |                    |
+----------------------------+--------------------+--------------------+
| Destination / Housing      | 1 (Emergency       |                    |
| Outcome \*                 | Shelter)=          |                    |
|                            | Emergency shelter  |                    |
| *(\* this section          | or potentially     |                    |
| rearranged to the HOPWA    | place not meant    |                    |
| outcome focus from HMIS    | for habitation     |                    |
| standards)*                | (e.g., a vehicle,  |                    |
|                            | an abandoned       |                    |
|                            | building,          |                    |
|                            | bus/train/subway   |                    |
|                            | station/airport,   |                    |
|                            | or anywhere        |                    |
|                            | outside)           |                    |
|                            |                    |                    |
|                            | 2 (Temporary       |                    |
|                            | Housing) =         |                    |
|                            | Temporary          |                    |
|                            | arrangement such   |                    |
|                            | as Transitional    |                    |
|                            | housing for        |                    |
|                            | homeless persons;  |                    |
|                            | Staying or living  |                    |
|                            | in someone' else's |                    |
|                            | (family and        |                    |
|                            | friends) room,     |                    |
|                            | apartment, or      |                    |
|                            | house; Hotel or    |                    |
|                            | motel paid for     |                    |
|                            | without emergency  |                    |
|                            | shelter voucher;   |                    |
|                            | planned temporary  |                    |
|                            | stay in            |                    |
|                            | institution such   |                    |
|                            | as a Substance     |                    |
|                            | abuse treatment    |                    |
|                            | facility or detox  |                    |
|                            | center             |                    |
|                            |                    |                    |
|                            | 3 (Private         |                    |
|                            | Housing)=          |                    |
|                            | Non-subsidized     |                    |
|                            | rented room,       |                    |
|                            | apartment, or      |                    |
|                            | house; or House    |                    |
|                            | you own or other   |                    |
|                            | permanent          |                    |
|                            | placement without  |                    |
|                            | subsidy            |                    |
|                            |                    |                    |
|                            | 4 (Other           |                    |
|                            | HOPWA)=such as     |                    |
|                            | TBRA or housing    |                    |
|                            | facilities.        |                    |
|                            |                    |                    |
|                            | 5 (Other Subsidy)= |                    |
|                            | non-HOPWA          |                    |
|                            | subsidized         |                    |
|                            | housing, such as   |                    |
|                            | Section 8, HOME,   |                    |
|                            | Permanent housing  |                    |
|                            | for formerly       |                    |
|                            | homeless persons   |                    |
|                            | (such as Shelter   |                    |
|                            | Plus Care, SHP, or |                    |
|                            | SRO Mod Rehab); or |                    |
|                            | Hospital           |                    |
|                            | (non-psychiatric)  |                    |
|                            |                    |                    |
|                            | 6 (Institution)=   |                    |
|                            | Psychiatric        |                    |
|                            | hospital or other  |                    |
|                            | psychiatric        |                    |
|                            | facility; Foster   |                    |
|                            | care home or       |                    |
|                            | foster care group  |                    |
|                            | home; or other     |                    |
|                            | residence or       |                    |
|                            | long-term care     |                    |
|                            | facility           |                    |
|                            |                    |                    |
|                            | 7 (Jail/Prison) =  |                    |
|                            | Jail, prison, or   |                    |
|                            | juvenile detention |                    |
|                            | facility           |                    |
|                            |                    |                    |
|                            | 8 (Disconnected) = |                    |
|                            | Don't Know,        |                    |
|                            | Refused or no      |                    |
|                            | assessment of      |                    |
|                            | housing needs were |                    |
|                            | undertaken         |                    |
|                            |                    |                    |
|                            | 9 (Death) = life   |                    |
|                            | event              |                    |
+----------------------------+--------------------+--------------------+
| Tenure                     | 1=Permanent        |                    |
|                            |                    |                    |
|                            | 2=Transitional     |                    |
|                            |                    |                    |
|                            | 8=Don't Know       |                    |
|                            |                    |                    |
|                            | 9=Refused          |                    |
+----------------------------+--------------------+--------------------+
| Subsidy Type               | 1=Public housing   | 6=None             |
|                            |                    |                    |
|                            | 2=Section 8        | 8=Don't Know       |
|                            |                    |                    |
|                            | 3=Shelter Plus     | 9=Refused          |
|                            | Care               |                    |
|                            |                    | 10=HOPWA program   |
|                            | 4=HOME program     |                    |
|                            |                    |                    |
|                            | 5=Other subsidy    |                    |
+----------------------------+--------------------+--------------------+
| Housing Assistance         | 1=Short-term Rent, |                    |
|                            | Mortgage, and      |                    |
|                            | Utility            |                    |
|                            |                    |                    |
|                            | 2=Tenant-based     |                    |
|                            | Rental Assistance  |                    |
|                            |                    |                    |
|                            | 3=Facility-based   |                    |
|                            | Housing Assistance |                    |
|                            |                    |                    |
|                            | a=Single Room      |                    |
|                            | Occupancy building |                    |
|                            |                    |                    |
|                            | b=Community        |                    |
|                            | Residence          |                    |
|                            |                    |                    |
|                            | c=Units leased by  |                    |
|                            | project sponsor    |                    |
|                            | (non               |                    |
|                            | facility-based or  |                    |
|                            | clustered)         |                    |
|                            |                    |                    |
|                            | d=Other Housing    |                    |
|                            | Facility (please   |                    |
|                            | specify)           |                    |
+----------------------------+--------------------+--------------------+
| EXTRA. HOPWA access to     | 1\. Has a housing  |                    |
| care and other support \*  | plan for           |                    |
|                            | maintaining or     |                    |
| *(added to HMIS            | establishing       |                    |
| standards)*                | stable on-going    |                    |
|                            | housing            |                    |
|                            |                    |                    |
|                            | 2\. Has contact    |                    |
|                            | with case          |                    |
|                            | manager/benefits   |                    |
|                            | counselor          |                    |
|                            | consistent with    |                    |
|                            | the schedule       |                    |
|                            | specified in       |                    |
|                            | client's           |                    |
|                            | individual service |                    |
|                            | plan.              |                    |
|                            |                    |                    |
|                            | 3\. Had contact    |                    |
|                            | with a primary     |                    |
|                            | health care        |                    |
|                            | provider           |                    |
|                            | consistent with    |                    |
|                            | the schedule       |                    |
|                            | specified in       |                    |
|                            | client's           |                    |
|                            | individual service |                    |
|                            | plan.              |                    |
|                            |                    |                    |
|                            | 4\. Has accessed   |                    |
|                            | and can maintain   |                    |
|                            | medical            |                    |
|                            | ins                |                    |
|                            | urance/assistance. |                    |
|                            |                    |                    |
|                            | 5\. Successfully   |                    |
|                            | accessed or        |                    |
|                            | maintained         |                    |
|                            | qualification for  |                    |
|                            | sources of income. |                    |
+----------------------------+--------------------+--------------------+
| EXTRA. HOPWA access to     | Total number of    |                    |
| care and other support:    | households that    |                    |
| Obtained Employment \*     | obtained an        |                    |
|                            | income-producing   |                    |
| *(added to HMIS            | job                |                    |
| standards)*                |                    |                    |
+----------------------------+--------------------+--------------------+