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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 07/31/2007

.

**HOPWA Annual Progress Report (APR)**

OMB Number 2506-0133 Expiration Date 07/31/2007

**Overview**

In this APR edition, the U.S. Department of Housing and Urban
Development is emphasizing grantee performance and the use of client
outcome measures in demonstrating program effectiveness. Toward this
end, the HOPWA APR for competitive grant recipients has been revised to
incorporate new performance measure reporting requirements. These are
designed to help grantees and project sponsors aggregate results from
the use of HOPWA resources: (1) to provide housing assistance as the
annual output measure; and (2) to collect client information
demonstrating the outcome for improved housing stability for this
special needs population. Formula grantees also may want to use this
form to track client information. HUD collaborated with grantees and
technical assistance providers to implement the reporting information to
measure this new performance outcome. This outcome measure will identify
HOPWA assisted households that have been enabled to establish and/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 health care and
other support. At the end of each year of assistance, HOPWA recipients
should consider the effects of their efforts under this general outcome.
Recipients need to assess accomplishments in achieving this outcome and
report on program progress. These assessments will help inform the
community as well as HUD in assessing past performance and helping to
direct future efforts. Additionally, programs can use the information to
consider alternatives or program enhancements if activities are not
meeting the stated outcome.

HOPWA collects the necessary information under the authority of the AIDS
Housing Opportunity Act (AHOA), as amended, 42 U.S.C. 12901-12912. This
Act authorizes HUD to provide states and localities with the resources
and incentives to devise long‑term comprehensive strategies for meeting
the housing needs of persons living with acquired immune deficiency
syndrome (AIDS) or HIV infection and their families. The statute
includes the following provisions that necessitate the collection of
this information: (1) The AHOA authorizes the Department to conduct a
national competition for the award of funds for ten percent of the
annual appropriation for the HOPWA program; and (2) The AHOA requires
that recipients of assistance report on the use of amounts received,
including the number of individuals assisted, the types of assistance
provided, and other information determined to be appropriate.

HUD selects the highest rated applicants for special projects of
national significance and applicants for projects that are part of
long‑term comprehensive strategies for providing housing and related
services in areas that do not qualify for formula allocations. As
authorized, competitive grants that provide permanent supportive housing
and meet program requirements may be selected on a priority basis for
renewal funding. Annual Progress Reports provide HUD with essential
information on project output and outcome activities in reporting to
Congress and the public on the use of program funds. In addition, the
reports assist HUD in monitoring the use of federal funds and ensuring
statutory and regulatory compliance. Information is collected on an
annual basis in the application to make selections and in the annual
progress report to report on program activities based on statutory
requirements at 42 U.S.C. 12903(b)(3) and 12911. Less frequent
submission of information on program accomplishments could compromise
the legal, efficient, and effective implementation of the program. The
information to be submitted by applicants and recipients is considered
public information, except to the extent that applications contain
personal or proprietary information or are in use for the competition
during a covered use period pursuant to the Department of Housing and
Development Reform Act of 1989 (Pub. L. 101-235, as amended).

In addition to the Department's review of performance outcomes, HUD is
consciously streamlining reporting requirements through integration and
standardization of reporting mechanisms, to the extent possible. Since
2003, all competitive grantees are required as part of the grant
agreements to complete a logic model which is a performance tool that
informs HUD, the public, and other grantees on how grantees' services
and activities help achieve HUD strategic goals and promote HUD policy
priorities. The required APR information helps provide the information
necessary for completing the logic model on the required HOPWA output
measure, the amount of housing assistance provided each year, and to
assess client outcomes in achieving housing stability.

**General Instructions**

**Purpose.** The Annual Progress Report (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.

**Applicability.** Grantees must complete the 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. A formula grantee
may use this as an optional form, for example in collecting standard
information from project sponsors, but will still be obligated to
fulfill formula reporting requirements. Grantees must complete all of
Parts 1-3 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. For instance,
accomplishment data may be included in Part 2c.

On Part 3, grantees are required to complete project sponsor information
in subparts (a-c) that correspond to activities undertaken with HOPWA
funding, i.e., tenant-based rental assistance (TBRA) (Part 3A),
short-term rent, mortgage and utility assistance (STRMU) (Part 3A),
facility-based housing assistance (FBHA) (Part 3B), or supportive
services only projects (Part 3C). Grantees whose activities are limited
to providing supportive services only (Part 3C) are not required to
provide information relating to participant demographics. Grantees
providing housing assistance must complete Part 2A Information on
Individuals, Beneficiaries and Households, Part 2B Budget and Grant
Sources for Project Leveraging, Part 2C Performance and Expenditure
Information and Part 2D Housing Stability Outcomes; and Outcomes on
Access to Care and Support (for clients served with Housing Placement
Activities, Case management and employment training services) for their
clients who benefit from the HOPWA housing assistance.

**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.
For the years in which grantees do not receive and expend HOPWA funding
for these activities, 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 3b
Facility Based Housing Assistance in this APR.

**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 identifications. 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
one operating year of the grantee's report. Project sponsor
accomplishment information must reflect the same time period as the
grantee's operating year and APR dates. New grantees have some
flexibility in setting the dates of operating years. A grantee of a
competitively‑awarded grant may set the operating start date for its
program on a date up to four months following the date of the signing of
the grant agreement. 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.

**Organization of the Report.** The information included in this report
has been organized to facilitate reporting by project sponsors to allow
grantees to assemble the parts applicable to reporting on its
HUD-approved grant.

1)  Grantee Narrative and Performance Assessment

2)  Overview of Grant Activities and Expenditures \-- Summary of All
    Projects

    a.  Information on Individuals, Beneficiaries and Households

    b.  Summary of Grantee Leveraging

    c.  Performance and Expenditure Information

    d.  HOPWA Performance Outcomes

3)  Project Sponsor Information (each project sponsor)

    a.  Non facility-based Housing Assistance

    b.  Facility-based Housing Assistance

    c.  Supportive Services-Only Projects

4)  Appendix: Information on Outcomes and HMIS

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

**Filing Requirements.** Within 90 days after the end of each operating
year, the information in this package must be submitted to the Director
of the Office of Community Planning and Development (CPD) in the
grantee's State or Area HUD Office, with one copy submitted to the
Office of HIV/AIDS Housing (Room 7212), U.S. Department of Housing and
Urban Development, 451 Seventh Street SW, Washington, D.C. 20410.
Failure to timely submit the required Annual Progress Report may lead to
a delay in receiving future grant funds or a determination for
ineligibility for future funding.

**Definitions.** The HOPWA regulations provide definitions at 24 CFR
574.3. The following terms supplement these definitions for the use of
preparing this APR.

**Adjustment for Duplication:** Refers to number of households or
beneficiaries that received more than one type of assistance in a given
service category. The adjustment for duplication should provide an
unduplicated total.

**Administrative Costs:** Refers to 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 total grant award, to be expended over
the life of the grant.

**At Entry or Continuing:** At Entry indicates the household status at
the time of when eligibility and housing needs are assessed. For
households continuing from the previous year, the entry date would be
the status of the household at the beginning of the operating year.

**At Exit or Continuing:** At Exit indicates the household status at the
time of departure from the HOPWA program. For households continuing into
the next operating year, the exit date would be the status of the
household at the end of the new operating year. Exit, reasonable
expectation that additional support (e.g. Tent-based Rental Assistance)
is not required to maintain housing arrangements.

**Beneficiary:** A beneficiary is any individual who received HOPWA
housing assistance during the operating year. And includes all members
of the household receiving assistance.

**HOPWA Eligible Person:** The 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
please 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:** A "chronically homeless person" is "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 "disabling condition" is "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.

**Entered the program:** This phrase means when the participant's
eligibility and housing needs are assessed, housing plan is established,
or the person or family starts to receive rental assistance or begins
residing at the housing facility.

**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 HOPWA Housing expenditures
for the current operating year to support facilities including community
residences, SRO dwellings, short-term facilities, project-based units,
master leased units, and other housing facilities approved by HUD, and
supportive services only facilities.

**Grassroots organization:** A "grassroots organization" means an
organization that is headquartered in the local community to which it
provides services; and, (i) has a social services budget of \$300,000 or
less, or (ii) has six or fewer full-time equivalent employees. Local
affiliates of national organizations are not considered "grassroots."

**Household:** A "household" means 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 4 Appendix (page 23) for definitions of
stable and unstable Housing situations.

**Multiple Diagnosed Issues:** A disease or condition, such as serious
mental illness or substance abuse, co-existing with risk of homelessness
for persons living with HIV/AIDS.

**Non-Facility based Housing Assistance:** All HOPWA Housing
expenditures for the current operating year to support tenant-based
rental assistance or short-term, rent, mortgage, and utility assistance.

**Non-HOPWA leveraged sources:** Non-HOPWA leveraged resources refers to
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 at 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.

**Output Assessed:** Output refers to the number of units of
housing/households assisted during the year, as measured by the annual
use of HOPWA funds.

**Outcome Assessed:** 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 with the goal
that this result increases through use of annual resources to be
achieved by 80 percent of all HOPWA beneficiaries by 2008.

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

**Stewardship Unit:** Facility based housing units developed with HOPWA
funds, but have no current operations or other HOPWA costs and is
subject to 3- or 10- year use periods.

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

**Annual Progress Report -- Measuring Project Performance**

OMB Number 2506-0133 Expiration Date 07/31/2007

+-----------------------------------+-----------------------------------+
| **HUD Grant Number**              | **Operating Year for this         |
|                                   | report**                          |
| **     **                         |                                   |
|                                   | ***From (mm/dd/yy)*** ***      to |
|                                   | (mm/dd/yy)***                     |
|                                   |                                   |
|                                   | Yr 1; Yr 2; Yr 3; ExtYr           |
+-----------------------------------+-----------------------------------+
| **Grantee Name**                  |                                   |
|                                   |                                   |
| **     **                         |                                   |
+-----------------------------------+-----------------------------------+
| **Type of HOPWA Grant**           | **Service Area (community,        |
|                                   | Metropolitan Statistical Area     |
| Competitive                       | (MSA) or State in which this      |
|                                   | program is operating)**           |
| Technical Assistance              |                                   |
|                                   | **     **                         |
| Formula                           |                                   |
+-----------------------------------+-----------------------------------+
| *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 & 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)*                         |                                   |
|                                   |                                   |
| **     **                         |                                   |
+-----------------------------------+-----------------------------------+
| **Address**                       | **Fax Number (include area        |
|                                   | code)**                           |
| **     **                         |                                   |
|                                   | **     **                         |
+-----------------------------------+-----------------------------------+
| **City, State, Zip**              | **Email Address**                 |
|                                   |                                   |
| **     **                         | **     **                         |
+-----------------------------------+-----------------------------------+
| **Organization's Website          | **Type of Agency**                |
| Address**                         |                                   |
|                                   | **     **                         |
| **     **                         |                                   |
|                                   | Is the grantee a nonprofit        |
|                                   | organization? Yes No              |
|                                   |                                   |
|                                   | *Check if the grantee is a        |
|                                   | faith-based organization.*        |
|                                   |                                   |
|                                   | *Check if the grantee is a        |
|                                   | grassroots organization.*         |
+-----------------------------------+-----------------------------------+
| **Have you prepared any           |                                   |
| evaluation report?\               |                                   |
| ***If so, please indicate its     |                                   |
| location on an Internet site      |                                   |
| (url) or attach copy.*            |                                   |
+-----------------------------------+-----------------------------------+

**Part 1: Grantee Narrative and Performance Assessment**

[]{.mark}

**Instructions:** Provide a short narrative summarizing the activities
undertaken during the operating year for this grant (1-4 pages) that may
be used for public information, including posting on HUD's web page. In
the summary, describe any project sponsors and partner organizations;
report innovative outreach and support provided to the target
population; and any related assessment or evaluation of the project's
accomplishments conducted during the operating year. In conjunction with
an updated logic model, submit a summary reporting the following:

a\. **OUTPUTS REPORTED:** Provide an overview of your program's
accomplishments for the operating year, report on the number of units of
housing supported/households assisted with HOPWA housing assistance
funds during this operating year. Include a comparison between proposed
accomplishments, as approved in the grant agreement, with the actual
accomplishments demonstrated in Part 2: Overview of Grant Activities.

     

b\. **OUTCOMES ASSESSED:** Please describe progress in achieving HOPWA
performance outcomes. Briefly assess how HOPWA assisted households were
enabled to establish and/or better maintain a stable living environment
in housing that is safe, decent, and sanitary, and reduce their risks of
homelessness and improve their access to health-care and other
supportive services. Compare current year outcomes with any baseline of
prior efforts.

     

c\. **BARRIERS AND RECOMMENDATIONS:** Describe any barriers you or your
project sponsors encountered during the operating year, actions taken in
response to the barriers, and recommendations for program improvement.
You may select more than one from the following list:

  -----------------------------------------------------------------------
  HOPWA/HUD Regulations Planning Issues Housing Availability Rent
  Determination and Fair Market Rents Discrimination/Confidentiality
  Multiple Diagnosed Issues Eligibility Issues Technical Assistance or
  Training Issues Supportive Services

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

     

d\. **TECHNICAL ASSISTANCE:** Based on your experience during the last
operating year, are there any areas in which you need technical advice
or assistance? If so, please describe.

[]{.mark}

[]{.mark}

     

[]{.mark}

e\. **LOGIC MODEL:** Please attach a copy of your grants' updated Logic
Model on your annual accomplishments und the HOPWA performance goals and
the optional goals you established in your application. *\*Reference
(data requested consistent with Form HUD-96010 Program Outcome Logic
Model)*

[]{.mark}

[]{.mark}

[]{.mark}

[]{.mark}

[]{.mark}

[]{.mark}

**Part 2: Overview of Grant Activities - Summary of All Projects**

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

> **1. Individuals**
>
> **[Eligible Individuals]{.underline} living with HIV/AIDS:** Please
> indicate below the unduplicated number of eligible individuals (Head
> of Household) who are [low income and living with
> HIV/AIDS,]{.underline} who received HOPWA housing assistance during
> the operating year. Of those eligible individuals, indicate who have
> special needs and their prior living situations.
>
> **a. Total HOPWA eligible individuals living with HIV/AIDS:** Please
> indicate below the unduplicated number of eligible individuals who are
> [low income and living with HIV/AIDS]{.underline}, who received HOPWA
> housing assistance during the operating year.

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

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

**b. Special Needs:** Please indicate the total number of HOPWA eligible
individuals living with HIV/AIDS, who received HOPWA housing assistance
and had the following life experiences, if known. Participants may count
in more than one category. *The sum total of individuals identified with
Special Needs issues may not equal the total number of individuals
served with HOPWA housing assistance from (a) above.*

  --------------------------------- -------------- ------------- ---------------
  **Category**                      **i.           **ii.         **iii. Domestic
                                    Veteran(s)**   Chronically   Violence
                                                   Homeless**    Survivor(s)**

  **Total HOPWA eligible persons                                 
  Served with Housing Assistance**                               
  --------------------------------- -------------- ------------- ---------------

**c. Prior living situation.** Please indicate the prior living
situations for HOPWA eligible individuals living with HIV/AIDS, who
received HOPWA housing assistance. Include participants in the
**([one]{.underline})** category that best describes the participants'
most recent living situation. The total (xvii) in this section should
equal a (i) above. The categories are consistent with HMIS standard
responses.

+---+---+---------------------------------------------------+---------------+
| * |   |                                                   | **Total HOPWA |
| * |   |                                                   | eligible      |
| C |   |                                                   | persons       |
| a |   |                                                   | Served with   |
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+---+---+---------------------------------------------------+---------------+
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+---+---+---------------------------------------------------+---------------+
| * |   |                                                   |               |
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| n |   |                                                   |               |
| i |   |                                                   |               |
| n |   |                                                   |               |
| g |   |                                                   |               |
| H |   |                                                   |               |
| O |   |                                                   |               |
| P |   |                                                   |               |
| W |   |                                                   |               |
| A |   |                                                   |               |
| s |   |                                                   |               |
| e |   |                                                   |               |
| r |   |                                                   |               |
| v |   |                                                   |               |
| i |   |                                                   |               |
| c |   |                                                   |               |
| e |   |                                                   |               |
| s |   |                                                   |               |
| d |   |                                                   |               |
| u |   |                                                   |               |
| r |   |                                                   |               |
| i |   |                                                   |               |
| n |   |                                                   |               |
| g |   |                                                   |               |
| O |   |                                                   |               |
| p |   |                                                   |               |
| e |   |                                                   |               |
| r |   |                                                   |               |
| a |   |                                                   |               |
| t |   |                                                   |               |
| i |   |                                                   |               |
| n |   |                                                   |               |
| g |   |                                                   |               |
| Y |   |                                                   |               |
| e |   |                                                   |               |
| a |   |                                                   |               |
| r |   |                                                   |               |
| ) |   |                                                   |               |
| * |   |                                                   |               |
| * |   |                                                   |               |
+---+---+---------------------------------------------------+---------------+
| i |   | Place not meant for human habitation              |               |
| i |   |                                                   |               |
| \ |   | (such as a vehicle, abandoned building,           |               |
| . |   | bus/train/subway station/airport, or outside)     |               |
+---+---+---------------------------------------------------+---------------+
| i |   | Emergency shelter (including hotel, motel, or     |               |
| i |   | campground paid for with emergency shelter        |               |
| i |   | voucher)                                          |               |
| \ |   |                                                   |               |
| . |   |                                                   |               |
+---+---+---------------------------------------------------+---------------+
| i |   | Transitional housing for homeless persons         |               |
| v |   |                                                   |               |
| \ |   |                                                   |               |
| . |   |                                                   |               |
+---+---+---------------------------------------------------+---------------+
| v |   | Permanent housing for formerly homeless persons   |               |
| \ |   | (such as Shelter Plus Care, SHP, or SRO Mod       |               |
| . |   | Rehab)                                            |               |
+---+---+---------------------------------------------------+---------------+
| v |   | Psychiatric hospital or other psychiatric         |               |
| i |   | facility                                          |               |
| \ |   |                                                   |               |
| . |   |                                                   |               |
+---+---+---------------------------------------------------+---------------+
| v |   | Substance abuse treatment facility or detox       |               |
| i |   | center                                            |               |
| i |   |                                                   |               |
| \ |   |                                                   |               |
| . |   |                                                   |               |
+---+---+---------------------------------------------------+---------------+
| v |   | Hospital (non-psychiatric facility)               |               |
| i |   |                                                   |               |
| i |   |                                                   |               |
| i |   |                                                   |               |
| \ |   |                                                   |               |
| . |   |                                                   |               |
+---+---+---------------------------------------------------+---------------+
| i |   | Foster care home or foster care group home        |               |
| x |   |                                                   |               |
| \ |   |                                                   |               |
| . |   |                                                   |               |
+---+---+---------------------------------------------------+---------------+
| x |   | Jail, prison or juvenile detention facility       |               |
| \ |   |                                                   |               |
| . |   |                                                   |               |
+---+---+---------------------------------------------------+---------------+
| x |   | Rented room, apartment, or house                  |               |
| i |   |                                                   |               |
| \ |   |                                                   |               |
| . |   |                                                   |               |
+---+---+---------------------------------------------------+---------------+
| x |   | House you own                                     |               |
| i |   |                                                   |               |
| i |   |                                                   |               |
| \ |   |                                                   |               |
| . |   |                                                   |               |
+---+---+---------------------------------------------------+---------------+
| x |   | Staying or living in someone else's (family and   |               |
| i |   | friends) room, apartment, or house                |               |
| i |   |                                                   |               |
| i |   |                                                   |               |
| \ |   |                                                   |               |
| . |   |                                                   |               |
+---+---+---------------------------------------------------+---------------+
| x |   | Hotel or motel paid for without emergency shelter |               |
| i |   | voucher                                           |               |
| v |   |                                                   |               |
| \ |   |                                                   |               |
| . |   |                                                   |               |
+---+---+---------------------------------------------------+---------------+
| x |   | Other                                             |               |
| v |   |                                                   |               |
| \ |   |                                                   |               |
| . |   |                                                   |               |
+---+---+---------------------------------------------------+---------------+
| x |   | Don't Know or Refused                             |               |
| v |   |                                                   |               |
| i |   |                                                   |               |
| \ |   |                                                   |               |
| . |   |                                                   |               |
+---+---+---------------------------------------------------+---------------+
| x |   | **TOTAL (add item i-xvi)**                        |               |
| v |   |                                                   |               |
| i |   |                                                   |               |
| i |   |                                                   |               |
| \ |   |                                                   |               |
| . |   |                                                   |               |
+---+---+---------------------------------------------------+---------------+

**2. Beneficiaries**

**Demographics of Total Number of HOPWA Beneficiaries Served with
Housing Assistance.** *Please report the demographic information for 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).* Indicate the age, gender, and race and ethnicity for all
beneficiaries. The sum of **[each]{.underline}** of the following
categories should equal the total number of beneficiaries served with
HOPWA housing assistance.

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

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

  i\. Number of individuals with HIV/AIDS who received 
  HOPWA housing assistance (from item 1a, line i       
  above)                                               

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

  iii\. **TOTAL number of [beneficiaries]{.underline}  
  served with Housing Assistance (lines i + ii)**      
  ---------------------------------------------------- ------------------

**b. Age and Gender**

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

  i\.            Under 18                                                        

  ii\.           18 to 30                                                        
                 years                                                           

  iii\.          31 to 50                                                        
                 years                                                           

  iv\.           51 years                                                        
                 and Older                                                       
  -------------- ----------- ---------- ------------ --------- ----------------- -----------

**c. Race and Ethnicity\***

+---+--------------+-------+-------+---+------------+--------+--------+
|   | #            | **    | **    |   | **         | *      | *      |
|   |              | Total | Total |   | Category** | *Total | *Total |
|   | #            | Ben   | Ben   |   |            | B      | B      |
|   |              | efici | efici |   |            | enefic | enefic |
|   | # **Racial   | aries | aries |   |            | iaries | iaries |
|   | Categories** | S     | who   |   |            | Served | who    |
|   |              | erved | are   |   |            | with   | are    |
|   |              | with  | also  |   |            | H      | also   |
|   |              | Ho    | His   |   |            | ousing | Hi     |
|   |              | using | panic |   |            | Assist | spanic |
|   |              | As    | or    |   |            | ance** | or     |
|   |              | sista | Lat   |   |            |        | La     |
|   |              | nce** | ino** |   |            |        | tino** |
+---+--------------+-------+-------+---+------------+--------+--------+
| i | American     |       |       | v | American   |        |        |
| \ | In           |       |       | i | Indi       |        |        |
| . | dian/Alaskan |       |       | \ | an/Alaskan |        |        |
|   | Native       |       |       | . | Native &   |        |        |
|   |              |       |       |   | White      |        |        |
+---+--------------+-------+-------+---+------------+--------+--------+
| i | Asian        |       |       | v | Asian &    |        |        |
| i |              |       |       | i | White      |        |        |
| \ |              |       |       | i |            |        |        |
| . |              |       |       | \ |            |        |        |
|   |              |       |       | . |            |        |        |
+---+--------------+-------+-------+---+------------+--------+--------+
| i | B            |       |       | v | Bla        |        |        |
| i | lack/African |       |       | i | ck/African |        |        |
| i | American     |       |       | i | American   |        |        |
| \ |              |       |       | i | and White  |        |        |
| . |              |       |       | \ |            |        |        |
|   |              |       |       | . |            |        |        |
+---+--------------+-------+-------+---+------------+--------+--------+
| i | Native       |       |       | i | American   |        |        |
| v | Ha           |       |       | x | Indi       |        |        |
| \ | waiian/Other |       |       | \ | an/Alaskan |        |        |
| . | Pacific      |       |       | . | Native &   |        |        |
|   | Islander     |       |       |   | Bla        |        |        |
|   |              |       |       |   | ck/African |        |        |
|   |              |       |       |   | American   |        |        |
+---+--------------+-------+-------+---+------------+--------+--------+
| v | White        |       |       | x | Other      |        |        |
| \ |              |       |       | \ | Mu         |        |        |
| . |              |       |       | . | lti-Racial |        |        |
+---+--------------+-------+-------+---+------------+--------+--------+

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

**3. Households**

**Household Area Median Income:** Please indicate the area median income
for all households served with Housing Assistance. Total households
served should equal the number of households in Part 2C (5). For
information on area median income in your area, please refer to
[www.hud.gov](http://www.hud.gov/).

+---+------------------------------------------------+----------------+
| # |                                                | **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 |                                                |                |
|   |                                                |                |
| b |                                                |                |
| y |                                                |                |
|   |                                                |                |
| a |                                                |                |
| r |                                                |                |
| e |                                                |                |
| a |                                                |                |
| * |                                                |                |
| * |                                                |                |
+---+------------------------------------------------+----------------+
| i | 0-30% of area median income (extremely low)    |                |
| \ |                                                |                |
| . |                                                |                |
+---+------------------------------------------------+----------------+
| i | 31-50% of area median income (very low)        |                |
| i |                                                |                |
| \ |                                                |                |
| . |                                                |                |
+---+------------------------------------------------+----------------+
| i | 51-60% of area median income (low)             |                |
| i |                                                |                |
| i |                                                |                |
| \ |                                                |                |
| . |                                                |                |
+---+------------------------------------------------+----------------+
| i | 61-80% of area median income (low)             |                |
| v |                                                |                |
| \ |                                                |                |
| . |                                                |                |
+---+------------------------------------------------+----------------+

**Part 2: Overview of Grant Activities - Summary of All Projects**

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

All grantees receiving funds under the HOPWA program must complete this
chart for each operating year. Please identify the amount and source(s)
of cash resources leveraged from other sources, and used in delivery or
operation of HOPWA activities. Identification of in-kind and donated
services, value of buildings, etc., are not requested. Use additional
pages if necessary.**\
**

  ------------------------ ----------------------------------------------
  **Available HOPWA        i\) HOPWA 3-year grant award: \$     
  Funding**                

                           ii\) Prior year(s) Expenditures (for this
                           grant only): \$     

                           iii\) Current year Expenditure: \$     

                           iv\) Current HOPWA balance: (equals i --
                           \[ii+iii\]) \$     
  ------------------------ ----------------------------------------------

+----+--------------------------------------+-------------------------+
| *  |                                      | **Total Amount of       |
| *S |                                      | Leveraged Dollars (for  |
| ou |                                      | this operating year)**  |
| rc |                                      |                         |
| es |                                      |                         |
| of |                                      |                         |
| Le |                                      |                         |
| ve |                                      |                         |
| ra |                                      |                         |
| gi |                                      |                         |
| ng |                                      |                         |
| (  |                                      |                         |
| ca |                                      |                         |
| sh |                                      |                         |
| re |                                      |                         |
| so |                                      |                         |
| ur |                                      |                         |
| ce |                                      |                         |
| s) |                                      |                         |
| ** |                                      |                         |
+----+--------------------------------------+-------------------------+
|    | HOPWA (other formula/competitive     | \$                      |
|    | grants).                             |                         |
|    |                                      |                         |
|    | Information for collection purposes  |                         |
|    | only, not considered leveraging.     |                         |
+----+--------------------------------------+-------------------------+
|    |                                      |                         |
+----+--------------------------------------+-------------------------+
| 1  | Federal government (please specify): | \$                      |
| \. |                                      |                         |
+----+--------------------------------------+-------------------------+
|    |                                      | \$                      |
+----+--------------------------------------+-------------------------+
|    |                                      | \$                      |
+----+--------------------------------------+-------------------------+
|    |                                      | \$                      |
+----+--------------------------------------+-------------------------+
| 2  | State government (please specify)    | \$                      |
| \. |                                      |                         |
+----+--------------------------------------+-------------------------+
|    |                                      | \$                      |
+----+--------------------------------------+-------------------------+
|    |                                      | \$                      |
+----+--------------------------------------+-------------------------+
|    |                                      | \$                      |
+----+--------------------------------------+-------------------------+
| 3  | Local government (please specify)    | \$                      |
| \. |                                      |                         |
+----+--------------------------------------+-------------------------+
|    |                                      | \$                      |
+----+--------------------------------------+-------------------------+
|    |                                      | \$                      |
+----+--------------------------------------+-------------------------+
|    |                                      | \$                      |
+----+--------------------------------------+-------------------------+
| 4  | Foundations and other private cash   | \$                      |
| \. | resources (please specify)           |                         |
+----+--------------------------------------+-------------------------+
|    |                                      | \$                      |
+----+--------------------------------------+-------------------------+
|    |                                      | \$                      |
+----+--------------------------------------+-------------------------+
|    |                                      | \$                      |
+----+--------------------------------------+-------------------------+
| 5  | Resident rent payments in facilities | \$                      |
| \. |                                      |                         |
+----+--------------------------------------+-------------------------+
| 6  | Grantee/project sponsor (Agency)     | \$                      |
|    | cash                                 |                         |
+----+--------------------------------------+-------------------------+
| 7  | **TOTAL (Sum of 1-6; same as**       | \$                      |
|    | **Part 2C item 21)**                 |                         |
+----+--------------------------------------+-------------------------+

[]{.mark}

*For information purposes only: Leveraged cash resources 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 at 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*

*Leveraged Funds include other funds used for on-site or other specific
activities directly connected to serving HOPWA clients, at the activity
or program level.*

**Part 2: Overview of Grant Activities - Summary of All Projects**

**C. Performance and Expenditure Information**

**Instructions:** The following chart is a summary of all grant
activities included in this APR. Please enter aggregate information from
all project sponsors that received HOPWA funds from the grantee during
the operating year by reporting the [total number of
households]{.underline} by housing subsidy type and the number of
households assisted in housing facilities along with the total amount of
HOPWA funds expended in each category. [Please note items 1-5 and 9-14
are measured in households and 6 and 7 are measured in housing
units]{.underline}. The Total Housing Assistance number provided
represents the [unduplicated]{.underline} number of households assisted
during the operating year (the annual output measure for HOPWA Program).
Please indicate the amount and source(s) of leveraged funds from other
sources that are directly connected to the HOPWA effort, including any
households supported with these funds. Please include the
project-leveraging (cash resources) total for all project sponsors and
grantee activities. Please refer to the definitions section for
clarification on terminology.

+---+-------------------+-----------+---------+------------+-----------+
| * |                   | **Number  | *       | **Number   | **Amount  |
| * |                   | of        | *Amount | of         | of        |
| H |                   | [House    | of      | [Hou       | Leveraged |
| o |                   | holds]{.u | HOPWA   | seholds]{. | Funds     |
| u |                   | nderline} | Funds   | underline} | E         |
| s |                   | Receiving | Exp     | Receiving  | xpended** |
| i |                   | HOPWA     | ended** | Related    |           |
| n |                   | Ass       |         | Support    |           |
| g |                   | istance** |         | with       |           |
| S |                   |           |         | Non-HOPWA  |           |
| u |                   |           |         | Sources**  |           |
| b |                   |           |         |            |           |
| s |                   |           |         |            |           |
| i |                   |           |         |            |           |
| d |                   |           |         |            |           |
| y |                   |           |         |            |           |
| A |                   |           |         |            |           |
| s |                   |           |         |            |           |
| s |                   |           |         |            |           |
| i |                   |           |         |            |           |
| s |                   |           |         |            |           |
| t |                   |           |         |            |           |
| a |                   |           |         |            |           |
| n |                   |           |         |            |           |
| c |                   |           |         |            |           |
| e |                   |           |         |            |           |
| * |                   |           |         |            |           |
| * |                   |           |         |            |           |
+---+-------------------+-----------+---------+------------+-----------+
| 1 | Tenant-based      |           |         |            |           |
| \ | Rental Assistance |           |         |            |           |
| . |                   |           |         |            |           |
+---+-------------------+-----------+---------+------------+-----------+
| 2 | Facility-based    |           |         |            |           |
| a | units that        |           |         |            |           |
| . | receive operating |           |         |            |           |
|   | subsidy: [Number  |           |         |            |           |
|   | of households     |           |         |            |           |
|   | suppo             |           |         |            |           |
|   | rted]{.underline} |           |         |            |           |
+---+-------------------+-----------+---------+------------+-----------+
| 2 | Facility-based    |           |         |            |           |
| b | units developed   |           |         |            |           |
| . | with capital      |           |         |            |           |
|   | funds and placed  |           |         |            |           |
|   | in service during |           |         |            |           |
|   | the operating     |           |         |            |           |
|   | year: [Number of  |           |         |            |           |
|   | households        |           |         |            |           |
|   | suppo             |           |         |            |           |
|   | rted]{.underline} |           |         |            |           |
+---+-------------------+-----------+---------+------------+-----------+
| 3 | Short-term Rent,  |           |         |            |           |
| \ | Mortgage, and     |           |         |            |           |
| . | Utility           |           |         |            |           |
|   | Assistance        |           |         |            |           |
+---+-------------------+-----------+---------+------------+-----------+
| 4 | **Adjustment to   | (     )   | (     ) | (     )    | (     )   |
| \ | eliminate         |           |         |            |           |
| . | duplication       |           |         |            |           |
|   | (subtract)**      |           |         |            |           |
+---+-------------------+-----------+---------+------------+-----------+
| 5 | **Total Housing   |           |         |            |           |
| \ | Assistance        |           |         |            |           |
| . | (unduplicated)**  |           |         |            |           |
+---+-------------------+-----------+---------+------------+-----------+
| * |                   | **Number  | *       | **Number   | **Amount  |
| * |                   | of        | *Amount | of         | of        |
| H |                   | [         | of      | [Units]{.  | Leveraged |
| o |                   | Units]{.u | HOPWA   | underline} | Funds     |
| u |                   | nderline} | Funds   | Receiving  | E         |
| s |                   | Receiving | Exp     | Related    | xpended** |
| i |                   | HOPWA     | ended** | Support    |           |
| n |                   | Ass       |         | with       |           |
| g |                   | istance** |         | Non-HOPWA  |           |
| D |                   |           |         | Sources**  |           |
| 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 |                   |           |         |            |           |
| ) |                   |           |         |            |           |
| * |                   |           |         |            |           |
| * |                   |           |         |            |           |
+---+-------------------+-----------+---------+------------+-----------+
| 6 | Facility-based    |           |         |            |           |
| \ | units being       |           |         |            |           |
| . | developed with    |           |         |            |           |
|   | capital funding   |           |         |            |           |
|   | but not yet       |           |         |            |           |
|   | opened (show      |           |         |            |           |
|   | units of housing  |           |         |            |           |
|   | planned)          |           |         |            |           |
+---+-------------------+-----------+---------+------------+-----------+
| 7 | Stewardship units |           | []      |            |           |
| \ | subject to 3- or  |           | {.mark} |            |           |
| . | 10- year use      |           |         |            |           |
|   | periods           |           |         |            |           |
+---+-------------------+-----------+---------+------------+-----------+
| 8 | **Total Housing   |           |         |            |           |
| \ | Development**     |           |         |            |           |
| . |                   |           |         |            |           |
+---+-------------------+-----------+---------+------------+-----------+
| * |                   | **Number  | *       | **Number   | **Amount  |
| * |                   | of        | *Amount | of         | of        |
| S |                   | [House    | of      | [Hou       | Leveraged |
| u |                   | holds]{.u | HOPWA   | seholds]{. | funds     |
| p |                   | nderline} | Funds   | underline} | from      |
| p |                   | Receiving | Exp     | Receiving  | Other     |
| o |                   | HOPWA     | ended** | Related    | Sources** |
| r |                   | Ass       |         | Support    |           |
| t |                   | istance** |         | with       |           |
| i |                   |           |         | Non-HOPWA  |           |
| v |                   |           |         | Sources**  |           |
| e |                   |           |         |            |           |
| S |                   |           |         |            |           |
| e |                   |           |         |            |           |
| r |                   |           |         |            |           |
| v |                   |           |         |            |           |
| i |                   |           |         |            |           |
| c |                   |           |         |            |           |
| e |                   |           |         |            |           |
| s |                   |           |         |            |           |
| * |                   |           |         |            |           |
| * |                   |           |         |            |           |
|   |                   |           |         |            |           |
| * |                   |           |         |            |           |
| * |                   |           |         |            |           |
| ( |                   |           |         |            |           |
| e |                   |           |         |            |           |
| x |                   |           |         |            |           |
| c |                   |           |         |            |           |
| l |                   |           |         |            |           |
| u |                   |           |         |            |           |
| d |                   |           |         |            |           |
| i |                   |           |         |            |           |
| n |                   |           |         |            |           |
| g |                   |           |         |            |           |
| H |                   |           |         |            |           |
| o |                   |           |         |            |           |
| u |                   |           |         |            |           |
| s |                   |           |         |            |           |
| i |                   |           |         |            |           |
| n |                   |           |         |            |           |
| g |                   |           |         |            |           |
| P |                   |           |         |            |           |
| l |                   |           |         |            |           |
| a |                   |           |         |            |           |
| c |                   |           |         |            |           |
| e |                   |           |         |            |           |
| m |                   |           |         |            |           |
| e |                   |           |         |            |           |
| n |                   |           |         |            |           |
| t |                   |           |         |            |           |
| A |                   |           |         |            |           |
| c |                   |           |         |            |           |
| t |                   |           |         |            |           |
| i |                   |           |         |            |           |
| v |                   |           |         |            |           |
| i |                   |           |         |            |           |
| t |                   |           |         |            |           |
| i |                   |           |         |            |           |
| e |                   |           |         |            |           |
| s |                   |           |         |            |           |
| ) |                   |           |         |            |           |
| * |                   |           |         |            |           |
| * |                   |           |         |            |           |
+---+-------------------+-----------+---------+------------+-----------+
| 9 | Supportive        |           |         |            |           |
| a | Services in       |           |         |            |           |
| . | conjunction with  |           |         |            |           |
|   | HOPWA housing     |           |         |            |           |
|   | activities (for   |           |         |            |           |
|   | total households  |           |         |            |           |
|   | assisted item 5)  |           |         |            |           |
|   | **^1^**           |           |         |            |           |
+---+-------------------+-----------+---------+------------+-----------+
| 9 | Supportive        |           |         |            |           |
| b | Services NOT in   |           |         |            |           |
| . | conjunction with  |           |         |            |           |
|   | housing           |           |         |            |           |
|   | activities (HOPWA |           |         |            |           |
|   | funded Supportive |           |         |            |           |
|   | Services Only)    |           |         |            |           |
|   | **^2^**           |           |         |            |           |
+---+-------------------+-----------+---------+------------+-----------+
| 1 | **Adjustment to   | (     )   | (     ) | (     )    | (     )   |
| 0 | eliminate         |           |         |            |           |
| \ | duplication       |           |         |            |           |
| . | (subtract)**      |           |         |            |           |
+---+-------------------+-----------+---------+------------+-----------+
| 1 | **Total           |           |         |            |           |
| 1 | Supportive        |           |         |            |           |
| \ | Services**        |           |         |            |           |
| . |                   |           |         |            |           |
+---+-------------------+-----------+---------+------------+-----------+

  ------------------ -------------------- ---------- ------------ ----------- ----------- -------------
  **Housing                                                                               
  Placement                                                                               
  Assistance                                                                              
  Activities ^3^**                                                                        

  12\.               Housing Information                                                       
                     Services                                                             

  13\.               Permanent Housing                                                         
                     Placement Services                                                   

  14\.               **Total Housing                                                           
                     Placement                                                            
                     Assistance**                                                         

  **Administration                                                                        
  and Management                                                                          
  Services**                                                                              

  15\.               Resource                                     []{.mark}                    
                     Identification to                                                    
                     establish,                                                           
                     coordinate and                                                       
                     develop housing                                                      
                     assistance resources                                                 
                     (includes Technical                                                  
                     Assistance in                                                        
                     Community Residence)                                                 

  16\.               Project                                      []{.mark}                    
                     Outcomes/Program                                                     
                     Evaluation (if                                                       
                     approved)                                                            

  17\.               Grantee                                      []{.mark}                    
                     Administration                                                       
                     (maximum 3% of total                                                 
                     of HOPWA grant)                                                      

  18\.               Project Sponsor                              []{.mark}                    
                     Administration                                                       
                     (maximum 7% of total                                                 
                     of HOPWA grant)                                                      

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

  20\.               **Total                                                                   
                     Administration &                                                     
                     Management**                                                         

  **Total Expended**                                                                      

  21\.               **Total Expenditures                                                      
                     (sum of lines 5, 8,                                                  
                     11, 14 & 20)**                                                       
  ------------------ -------------------- ---------- ------------ ----------- ----------- -------------

*NOTE: The term Household is used as the main reporting category when
gathering information on housing subsidy assistance (such as TBRA and
STRMU) and for residents of facilities. Housing units is the term
generally used to describe the size of the housing facility or community
residence that was planned or under development with program funds as
seen in Part 3B. or in the stewardship units ONLY section. Once in
operation, it is possible that a unit in a facility may assist more than
one household during the operating year, as tenants move in and out of
that unit, for example, in residency in a transitional facility or
relocation to other housing. The use of households as the standard
measure for individuals assisted will help track this changeover of
tenants, with information provided in the outcome section.*

1\. Supportive Services in conjunction with HOPWA Housing Assistance: if
money is spent on case management and employment training, outcomes must
be reported in Access to Care and Support (See Part 2D Section 2 a and b
Support in conjunction with HOPWA-funded Housing Assistance)

2\. Supportive Services not in conjunction with HOPWA Housing
Assistance: if money is spent on case management and employment
training, outcomes must be reported in Access to Care and Support (See
Part 2D Section 2 c Support not in conjunction with HOPWA-funded Housing
Assistance)

3\. Housing Placement Activities: if money is spent on housing placement
activities in conjunction with HOPWA Housing Assistance outcomes must be
reported in Access to Care and Support (See Part 2D Section 2 a and b
Support in conjunction with HOPWA-funded Housing Assistance); if not in
conjunction with HOPWA Housing Assistance outcomes must be reported in
Access to Care and Support (See Part 2D Section 2 c Support not in
conjunction with HOPWA-funded Housing Assistance).

**Part 2: Overview of Grant Activities - Summary of All Projects**

**D. HOPWA Performance Outcomes**

**Section: 1) Housing Stability**

-   In column 1, provide the total number of eligible households that
    received HOPWA housing assistance, by type of housing subsidy
    assistance. The information provided should coincide with the
    households provided in Part 2C, items 1-3.

-   In column 2, enter the number of eligible households continuing to
    access each type of housing subsidy assistance (may involve a
    temporary absence of not more than 90 days for treatment purposes,
    with an intent to return).

-   In column 3, enter the number of eligible households within each
    specified type of housing assistance who left the program component
    during the operating year by their housing destination. If a
    household fractured during the operating year, report only on the
    destination of the eligible individual living with HIV/AIDS. Refer
    to the destination codes that appear in Part 4: Appendix: Worksheet
    on Determining HOPWA Outcomes and Connections with HMIS. If
    uncertain how to categorize a particular destination, please refer
    to the glossary for definitions of destination codes.

+------------+-----------------+------------------+-------------------+
| **Type of  | **\[1\]\        | **\[2\]\         | **\[3\]\          |
| Housing    | Total Number of | Number of        | Number of Exited  |
| As         | Households      | Households       | Households        |
| sistance** | Receiving HOPWA | Continuing**     | Component and     |
|            | Assistance**    |                  | Destination**     |
+------------+-----------------+------------------+-------------------+
| **Te       |                 |                  | 1 (Emergency      |
| nant-based |                 |                  | Shelter) =        |
| Rental     |                 |                  |                   |
| As         |                 |                  |                   |
| sistance** |                 |                  |                   |
+------------+-----------------+------------------+-------------------+
|            |                 |                  | 2 (Temporary      |
|            |                 |                  | Housing) =        |
+------------+-----------------+------------------+-------------------+
|            |                 |                  | 3 (Private        |
|            |                 |                  | Housing) =        |
+------------+-----------------+------------------+-------------------+
|            |                 |                  | 4 (Other HOPWA) = |
|            |                 |                  |                   |
+------------+-----------------+------------------+-------------------+
|            |                 |                  | 5 (Other Subsidy) |
|            |                 |                  | =                 |
+------------+-----------------+------------------+-------------------+
|            |                 |                  | 6 (Institution) = |
|            |                 |                  |                   |
+------------+-----------------+------------------+-------------------+
|            |                 |                  | 7 (Jail/Prison) = |
|            |                 |                  |                   |
+------------+-----------------+------------------+-------------------+
|            |                 |                  | 8 (Disconnected)  |
|            |                 |                  | =                 |
+------------+-----------------+------------------+-------------------+
|            |                 |                  | 9 (Death) =       |
+------------+-----------------+------------------+-------------------+
| **Faci     |                 |                  | 1 (Emergency      |
| lity-based |                 |                  | Shelter) =        |
| Housing    |                 |                  |                   |
| As         |                 |                  |                   |
| sistance** |                 |                  |                   |
+------------+-----------------+------------------+-------------------+
|            |                 |                  | 2 (Temporary      |
|            |                 |                  | Housing) =        |
+------------+-----------------+------------------+-------------------+
|            |                 |                  | 3 (Private        |
|            |                 |                  | Housing) =        |
+------------+-----------------+------------------+-------------------+
|            |                 |                  | 4 (Other HOPWA) = |
|            |                 |                  |                   |
+------------+-----------------+------------------+-------------------+
|            |                 |                  | 5 (Other Subsidy) |
|            |                 |                  | =                 |
+------------+-----------------+------------------+-------------------+
|            |                 |                  | 6 (Institution) = |
|            |                 |                  |                   |
+------------+-----------------+------------------+-------------------+
|            |                 |                  | 7 (Jail/Prison) = |
|            |                 |                  |                   |
+------------+-----------------+------------------+-------------------+
|            |                 |                  | 8 (Disconnected)  |
|            |                 |                  | =                 |
+------------+-----------------+------------------+-------------------+
|            |                 |                  | 9 (Death) =       |
+------------+-----------------+------------------+-------------------+
|            |                 |                  |                   |
+------------+-----------------+------------------+-------------------+
| **         | **Total Number  | **Of the Total   | **Status of STRMU |
| Short-term | of Households   | number           | Assisted          |
| Housing    | Receiving HOPWA | Households       | Households at the |
| As         | Assistance**    | Receiving STRMU  | End of Operating  |
| sistance** |                 | Assistance this  | Year**            |
|            |                 | operating year** |                   |
+------------+-----------------+------------------+-------------------+
| **         |                 | **What number of | 1 (Emergency      |
| Short-term |                 | those households | Shelter) =        |
| Rent,      |                 | received STRMU   |                   |
| Mortgage,  |                 | Assistance in    |                   |
| and        |                 | the prior        |                   |
| Utility    |                 | operating        |                   |
| As         |                 | year:**          |                   |
| sistance** |                 |                  |                   |
|            |                 |                  |                   |
|            |                 |                  |                   |
|            |                 | **What number of |                   |
|            |                 | those households |                   |
|            |                 | received STRMU   |                   |
|            |                 | Assistance in    |                   |
|            |                 | the two (2)      |                   |
|            |                 | prior operating  |                   |
|            |                 | years (ago):**   |                   |
|            |                 |                  |                   |
|            |                 |                  |                   |
+------------+-----------------+------------------+-------------------+
|            |                 |                  | 2 (Temporary      |
|            |                 |                  | Housing) =        |
+------------+-----------------+------------------+-------------------+
|            |                 |                  | 3 (Private        |
|            |                 |                  | Housing)\* =      |
|            |                 |                  |                   |
+------------+-----------------+------------------+-------------------+
|            |                 |                  | 4 (Other HOPWA) = |
|            |                 |                  |                   |
+------------+-----------------+------------------+-------------------+
|            |                 |                  | 5 (Other Subsidy) |
|            |                 |                  | =                 |
+------------+-----------------+------------------+-------------------+
|            |                 |                  | 6 (Institution) = |
|            |                 |                  |                   |
+------------+-----------------+------------------+-------------------+
|            |                 |                  | 7 (Jail/Prison) = |
|            |                 |                  |                   |
+------------+-----------------+------------------+-------------------+
|            |                 |                  | 8 (Disconnected)  |
|            |                 |                  | =                 |
+------------+-----------------+------------------+-------------------+
|            |                 |                  | 9 (Death) =       |
+------------+-----------------+------------------+-------------------+

Note: The total of column 2 (number of households continuing HOPWA
assistance in the next operating year) and column 3 (number of
households that exited the program) should equal column 1 (total number
of households served during the operating year).

***\*For more information on Housing Stability Outcomes, please refer to
Part 4: Appendix found on page 23***

+-----------------------------------------------------------------------+
| **Part 2: Overview of Grant Activities - Summary of All Projects**    |
|                                                                       |
| **D. HOPWA Performance Outcomes**                                     |
+-----------------------------------------------------------------------+

**Section: 2) Access to Care and Support**

> **a. Support in conjunction with HOPWA-funded Housing Assistance.**
> Please report on the access to care and support for households
> receiving case management, employment training, and/or housing
> placement assistance ([ONLY]{.underline}) that is [in conjunction with
> HOPWA-funded housing assistance only]{.underline} (See Part 2C, item
> 9-a, 12 and 13). Report on the household status at program entry (or
> beginning of operating year for households continuing from previous
> year) and program exit (or end of operating year for households
> continuing services in the following operating year), [if eligible
> individual living with HIV/AIDS accessed services]{.underline}.

  ----------------------------------------- -------------- -------------- ------------
  **Category of Services Accessed**         **Number of                   **Number of
                                            Households                    jobs that
                                            receiving                     included
                                            HOPWA Housing                 health
                                            Assistance**                  benefits**

                                            **At Entry or  **At Exit or   
                                            Continuing**   Continuing**   

  i\. Has a housing plan for maintaining or                               
  establishing stable on-going residency                                  

  ii\. Had contact with a case                                            
  manager/benefit counselor at least once                                 
  in the last three months (or consistent                                 
  with the schedule specified in their                                    
  individualized service plan)                                            

  iii\. Had contact with a primary health                                 
  care provider at least once in the last                                 
  three months (or consistent with the                                    
  schedule specified in their                                             
  individualized service plan)                                            

  iv\. Had medical insurance coverage or                                  
  medical assistance                                                      

  v\. Obtained an income-producing job                                    
  created by this project sponsor during                                  
  the year                                                                

  vi\. Obtained an income-producing job                                   
  outside this agency during the year                                     
  ----------------------------------------- -------------- -------------- ------------

> **b. Income.** Report the household monthly income of households
> receiving case management, employment training, and/or housing
> placement assistance (ONLY) that is [in conjunction with HOPWA-funded
> housing assistance]{.underline} (See Part 2C, box 9-a).

  -------- --------------------- -------------- ---- -------- ---------------------- --------------
           **A. Monthly          **Number of                  **B. Monthly Household **Number of
           Household Income at   Households**                 Income at Exit/End of  Households**
           Entry or Residents                                 Year**                 
           continuing from prior                                                     
           Year End**                                                                

  i\.      No income                                 i\.      No income              

  ii\.     \$1-150                                   ii\.     \$1-150                

  iii\.    \$151 - \$250                             iii\.    \$151 - \$250          

  iv\.     \$251- \$500                              iv\.     \$251- \$500           

  v\.      \$501 - \$1,000                           v\.      \$501 - \$1,000        

  vi\.     \$1001- \$1500                            vi\.     \$1001- \$1500         

  vii\.    \$1501- \$2000                            vii\.    \$1501- \$2000         

  viii\.   \$2001 +                                  viii\.   \$2001 +               
  -------- --------------------- -------------- ---- -------- ---------------------- --------------

> **c. Support NOT in conjunction with HOPWA-funded Housing
> Assistance.** Please report on the access to care and support only for
> households receiving case management, employment training, and/or
> housing placement assistance (ONLY) that is [not in conjunction with
> HOPWA-funded housing assistance]{.underline} (See Part 2C, item 9-b,
> 12 and 13). Report on the [household status]{.underline} at program
> entry (or beginning of operating year for households continuing from
> previous year) and program exit (or end of operating year for
> households continuing services in the following operating year), [if
> eligible individual living with HIV/AIDS accessed
> services]{.underline}.

  ----------------------------------------- -------------- -------------- ------------
  **Category of Services Accessed**         **Number of                   **Number of
                                            Households                    jobs that
                                            receiving                     included
                                            HOPWA Housing                 health
                                            Assistance**                  benefits**

                                            **At Entry or  **At Exit or   
                                            Continuing**   Continuing**   

  i\. Has a housing plan for maintaining or                               
  establishing stable on-going residency                                  

  ii\. Had contact with a case                                            
  manager/benefit counselor at least once                                 
  in the last three months (or consistent                                 
  with the schedule specified in their                                    
  individualized service plan)                                            

  iii\. Had contact with a primary health                                 
  care provider at least once in the last                                 
  three months (or consistent with the                                    
  schedule specified in their                                             
  individualized service plan)                                            

  iv\. Had medical insurance coverage or                                  
  medical assistance                                                      

  v\. Obtained an income-producing job                                    
  created by this project sponsor during                                  
  the year                                                                

  vi\. Obtained an income-producing job                                   
  outside this agency during the year                                     
  ----------------------------------------- -------------- -------------- ------------

**Part 3: HOPWA Project Sponsor Information**

Complete general a project information table for [each]{.underline}
project sponsor funded by the grantee (or if the grantee conducts the
program activities directly). Attach corresponding performance sections
that apply to each HOPWA activity carried out by the project sponsor.

**1. General Project Information:**

+----------------------+---------------+--------+------+---+------------+
| **Project Sponsor    | **     **     |        |      |   |            |
| Agency Name**        |               |        |      |   |            |
+----------------------+---------------+--------+------+---+------------+
| **Name & Title of    | **     **     |        |      |   |            |
| Contact at Project   |               |        |      |   |            |
| Sponsor Agency\      |               |        |      |   |            |
| **                   |               |        |      |   |            |
+----------------------+---------------+--------+------+---+------------+
| **Email Address**    | **     **     |        |      |   |            |
+----------------------+---------------+--------+------+---+------------+
| **Business Address** |               |        |      |   |            |
+----------------------+---------------+--------+------+---+------------+
| **City, State, Zip** | **     **     |        | *    |   | **     **  |
|                      |               |        | *    |   |            |
| **\                  |               |        |   ** |   |            |
| **                   |               |        |      |   |            |
+----------------------+---------------+--------+------+---+------------+
| **Phone (include     | **     **     | **Fax  |      | * |            |
| area code)**         |               | Nu     |      | * |            |
|                      |               | mber** |      |   |            |
|                      |               |        |      |   |            |
|                      |               | **(i   |      |   |            |
|                      |               | nclude |      |   |            |
|                      |               | area   |      |   |            |
|                      |               | c      |      | * |            |
|                      |               | ode)** |      | * |            |
+----------------------+---------------+--------+------+---+------------+
| **Website**          | **     **     |        |      |   |            |
+----------------------+---------------+--------+------+---+------------+
|                      |               |        |      |   |            |
+----------------------+---------------+--------+------+---+------------+
| **Total HOPWA        | **     **     |        |      |   |            |
| Subcontract Amount   |               |        |      |   |            |
| for this             |               |        |      |   |            |
| Organization**       |               |        |      |   |            |
+----------------------+---------------+--------+------+---+------------+
| **Primary Service or |               |        |      |   |            |
| Site Information:**  |               |        |      |   |            |
|                      |               |        |      |   |            |
| **Project Zip        |               |        |      |   |            |
| Code(s)**            |               |        |      |   |            |
+----------------------+---------------+--------+------+---+------------+
| **Is the sponsor a   | **Yes**       |        |      |   |            |
| nonprofit            | **No**        |        |      |   |            |
| organization?**      |               |        |      |   |            |
|                      | *Please check |        |      |   |            |
|                      | if yes and a  |        |      |   |            |
|                      | faith-based   |        |      |   |            |
|                      | o             |        |      |   |            |
|                      | rganization.* |        |      |   |            |
|                      |               |        |      |   |            |
|                      | *Please check |        |      |   |            |
|                      | if yes and a  |        |      |   |            |
|                      | grassroots    |        |      |   |            |
|                      | o             |        |      |   |            |
|                      | rganization.* |        |      |   |            |
+----------------------+---------------+--------+------+---+------------+

Please attach the respective section of this form if project sponsor
provides any of the following activities:

+----------------------------------+-----------------------------------+
| **Activity**                     | **Section**                       |
+----------------------------------+-----------------------------------+
| Non facility-based Housing       | Part 3A                           |
| Assistance                       |                                   |
|                                  |                                   |
| Tenant-based Rental Assistance   |                                   |
|                                  |                                   |
| Short-term Rent, Mortgage and    |                                   |
| Utility Assistance               |                                   |
+----------------------------------+-----------------------------------+
| Facility-based Housing           | Part 3B                           |
| Assistance                       |                                   |
+----------------------------------+-----------------------------------+
| Facility-based Stewardship Units | 1-page certification              |
| ONLY                             |                                   |
|                                  | (at end of the facility-based     |
|                                  | housing assistance section)       |
+----------------------------------+-----------------------------------+
| Supportive Services Only         | Part 3C                           |
+----------------------------------+-----------------------------------+

**2. Summary of all Supportive Services, Housing Placement Assistance
and Administration and Management Services provided by this project
sponsor, [in conjunction with HOPWA-funded Housing
Assistance]{.underline}:** Please include an unduplicated\* total of all
supportive services, a break-out of all supportive services provided,
and all housing placement assistance and administration and management
activities provided by this project sponsor.

+---+---------------------------+--------------------+-----------------+
| * |                           | **Number of        | **Amount of     |
| * |                           | [House             | HOPWA Funds     |
| S |                           | holds]{.underline} | Expended by     |
| u |                           | Receiving HOPWA    | this project    |
| p |                           | Assistance from    | sponsor**       |
| p |                           | this project       |                 |
| o |                           | sponsor**          |                 |
| r |                           |                    |                 |
| t |                           |                    |                 |
| i |                           |                    |                 |
| v |                           |                    |                 |
| e |                           |                    |                 |
| S |                           |                    |                 |
| e |                           |                    |                 |
| r |                           |                    |                 |
| v |                           |                    |                 |
| i |                           |                    |                 |
| c |                           |                    |                 |
| e |                           |                    |                 |
| s |                           |                    |                 |
| \ |                           |                    |                 |
| * |                           |                    |                 |
| * |                           |                    |                 |
+---+---------------------------+--------------------+-----------------+
| a | **Total Supportive        |                    |                 |
| \ | Services Provided by this |                    |                 |
| . | project sponsor in        |                    |                 |
|   | conjunction with          |                    |                 |
|   | HOPWA-funded Housing      |                    |                 |
|   | Assistance                |                    |                 |
|   | (unduplicated)\***        |                    |                 |
+---+---------------------------+--------------------+-----------------+
| * |                           |                    |                 |
| * |                           |                    |                 |
| B |                           |                    |                 |
| r |                           |                    |                 |
| e |                           |                    |                 |
| a |                           |                    |                 |
| k |                           |                    |                 |
| - |                           |                    |                 |
| o |                           |                    |                 |
| u |                           |                    |                 |
| t |                           |                    |                 |
| o |                           |                    |                 |
| f |                           |                    |                 |
| S |                           |                    |                 |
| u |                           |                    |                 |
| p |                           |                    |                 |
| p |                           |                    |                 |
| o |                           |                    |                 |
| r |                           |                    |                 |
| t |                           |                    |                 |
| i |                           |                    |                 |
| v |                           |                    |                 |
| e |                           |                    |                 |
| S |                           |                    |                 |
| e |                           |                    |                 |
| r |                           |                    |                 |
| v |                           |                    |                 |
| i |                           |                    |                 |
| c |                           |                    |                 |
| e |                           |                    |                 |
| s |                           |                    |                 |
| p |                           |                    |                 |
| r |                           |                    |                 |
| o |                           |                    |                 |
| v |                           |                    |                 |
| i |                           |                    |                 |
| d |                           |                    |                 |
| e |                           |                    |                 |
| d |                           |                    |                 |
| b |                           |                    |                 |
| y |                           |                    |                 |
| t |                           |                    |                 |
| h |                           |                    |                 |
| i |                           |                    |                 |
| s |                           |                    |                 |
| P |                           |                    |                 |
| r |                           |                    |                 |
| o |                           |                    |                 |
| j |                           |                    |                 |
| e |                           |                    |                 |
| c |                           |                    |                 |
| t |                           |                    |                 |
| S |                           |                    |                 |
| p |                           |                    |                 |
| o |                           |                    |                 |
| n |                           |                    |                 |
| s |                           |                    |                 |
| o |                           |                    |                 |
| r |                           |                    |                 |
| A |                           |                    |                 |
| g |                           |                    |                 |
| e |                           |                    |                 |
| n |                           |                    |                 |
| c |                           |                    |                 |
| y |                           |                    |                 |
| ( |                           |                    |                 |
| t |                           |                    |                 |
| o |                           |                    |                 |
| t |                           |                    |                 |
| a |                           |                    |                 |
| l |                           |                    |                 |
| m |                           |                    |                 |
| a |                           |                    |                 |
| y |                           |                    |                 |
| e |                           |                    |                 |
| x |                           |                    |                 |
| c |                           |                    |                 |
| e |                           |                    |                 |
| e |                           |                    |                 |
| d |                           |                    |                 |
| a |                           |                    |                 |
| b |                           |                    |                 |
| o |                           |                    |                 |
| v |                           |                    |                 |
| e |                           |                    |                 |
| b |                           |                    |                 |
| e |                           |                    |                 |
| c |                           |                    |                 |
| a |                           |                    |                 |
| u |                           |                    |                 |
| s |                           |                    |                 |
| e |                           |                    |                 |
| t |                           |                    |                 |
| h |                           |                    |                 |
| e |                           |                    |                 |
| s |                           |                    |                 |
| a |                           |                    |                 |
| m |                           |                    |                 |
| e |                           |                    |                 |
| h |                           |                    |                 |
| o |                           |                    |                 |
| u |                           |                    |                 |
| s |                           |                    |                 |
| e |                           |                    |                 |
| h |                           |                    |                 |
| o |                           |                    |                 |
| l |                           |                    |                 |
| d |                           |                    |                 |
| s |                           |                    |                 |
| m |                           |                    |                 |
| a |                           |                    |                 |
| y |                           |                    |                 |
| b |                           |                    |                 |
| e |                           |                    |                 |
| s |                           |                    |                 |
| e |                           |                    |                 |
| r |                           |                    |                 |
| v |                           |                    |                 |
| e |                           |                    |                 |
| d |                           |                    |                 |
| i |                           |                    |                 |
| n |                           |                    |                 |
| m |                           |                    |                 |
| o |                           |                    |                 |
| r |                           |                    |                 |
| e |                           |                    |                 |
| t |                           |                    |                 |
| h |                           |                    |                 |
| a |                           |                    |                 |
| n |                           |                    |                 |
| o |                           |                    |                 |
| n |                           |                    |                 |
| e |                           |                    |                 |
| c |                           |                    |                 |
| a |                           |                    |                 |
| t |                           |                    |                 |
| e |                           |                    |                 |
| g |                           |                    |                 |
| o |                           |                    |                 |
| r |                           |                    |                 |
| y |                           |                    |                 |
| ) |                           |                    |                 |
| * |                           |                    |                 |
| * |                           |                    |                 |
+---+---------------------------+--------------------+-----------------+
| b | Adult day care and        |                    |                 |
| \ | personal assistance       |                    |                 |
| . |                           |                    |                 |
+---+---------------------------+--------------------+-----------------+
| c | Alcohol and drug abuse    |                    |                 |
| \ | services                  |                    |                 |
| . |                           |                    |                 |
+---+---------------------------+--------------------+-----------------+
| d | Case management/client    |                    |                 |
| \ | advocacy/ access to       |                    |                 |
| . | benefits & services       |                    |                 |
+---+---------------------------+--------------------+-----------------+
| e | Child care and other      |                    |                 |
| \ | child services            |                    |                 |
| . |                           |                    |                 |
+---+---------------------------+--------------------+-----------------+
| f | Education                 |                    |                 |
| \ |                           |                    |                 |
| . |                           |                    |                 |
+---+---------------------------+--------------------+-----------------+
| g | Employment assistance and |                    |                 |
| \ | training                  |                    |                 |
| . |                           |                    |                 |
+---+---------------------------+--------------------+-----------------+
| h | Health/medical/intensive  |                    |                 |
| \ | care services, if         |                    |                 |
| . | approved                  |                    |                 |
|   |                           |                    |                 |
|   | Note: Client records must |                    |                 |
|   | conform with 24 CFR       |                    |                 |
|   | §574.310                  |                    |                 |
+---+---------------------------+--------------------+-----------------+
| i | Legal services            |                    |                 |
| \ |                           |                    |                 |
| . |                           |                    |                 |
+---+---------------------------+--------------------+-----------------+
| j | Life skills management    |                    |                 |
| \ | (outside of case          |                    |                 |
| . | management)               |                    |                 |
+---+---------------------------+--------------------+-----------------+
| k | Meals/nutritional         |                    |                 |
| \ | services                  |                    |                 |
| . |                           |                    |                 |
+---+---------------------------+--------------------+-----------------+
| l | Mental health services    |                    |                 |
| \ |                           |                    |                 |
| . |                           |                    |                 |
+---+---------------------------+--------------------+-----------------+
| m | Outreach                  |                    |                 |
| \ |                           |                    |                 |
| . |                           |                    |                 |
+---+---------------------------+--------------------+-----------------+
| n | Transportation            |                    |                 |
| \ |                           |                    |                 |
| . |                           |                    |                 |
+---+---------------------------+--------------------+-----------------+
| o | Other (only if            |                    |                 |
| \ | HUD-approved):            |                    |                 |
| . |                           |                    |                 |
+---+---------------------------+--------------------+-----------------+
|   | **Housing Placement       | **Number of        | **Amount of     |
|   | Assistance Categories**   | Households         | HOPWA funds     |
|   |                           | Receiving HOPWA    | Expended by     |
|   |                           | Assistance from    | this project    |
|   |                           | this project       | sponsor**       |
|   |                           | sponsor**          |                 |
+---+---------------------------+--------------------+-----------------+
| p | Housing Information       |                    |                 |
| \ | Services                  |                    |                 |
| . |                           |                    |                 |
+---+---------------------------+--------------------+-----------------+
| q | Permanent Housing         |                    |                 |
| \ | Placement Services        |                    |                 |
| . |                           |                    |                 |
+---+---------------------------+--------------------+-----------------+
| r | Total Housing Placement   |                    |                 |
| \ | Assistance                |                    |                 |
| . |                           |                    |                 |
+---+---------------------------+--------------------+-----------------+
|   | **Administration and      |                    |                 |
|   | Management Services**     |                    |                 |
+---+---------------------------+--------------------+-----------------+
| s | Resource Identification   |                    |                 |
| \ | to establish, coordinate, |                    |                 |
| . | and develop housing       |                    |                 |
|   | assistance resources      |                    |                 |
+---+---------------------------+--------------------+-----------------+
| t | Project Outcomes/Program  |                    |                 |
| \ | Evaluation (if approved)  |                    |                 |
| . |                           |                    |                 |
+---+---------------------------+--------------------+-----------------+
| u | Project Sponsor           |                    |                 |
| \ | Administration (maximum   |                    |                 |
| . | 7% of total)              |                    |                 |
+---+---------------------------+--------------------+-----------------+
| v | Other Activity (if        |                    |                 |
| \ | approved in grant         |                    |                 |
| . | agreement) Specify:       |                    |                 |
+---+---------------------------+--------------------+-----------------+
| w | **Total Administration &  |                    |                 |
| \ | Management**              |                    |                 |
| . |                           |                    |                 |
+---+---------------------------+--------------------+-----------------+
| x | **Total Expenditures (sum |                    |                 |
| \ | of items a + r +w)**      |                    |                 |
| . |                           |                    |                 |
+---+---------------------------+--------------------+-----------------+

**Part 3: HOPWA Project Sponsor Information**

**A. Non facility-based Housing Assistance**

**1. Tenant-Based Rental Assistance (TBRA):** For project sponsors that
provided Tenant-based Rental Assistance (TBRA) using HOPWA funds during
the Report Year indicated in Part 3, please provide the following
detailed information for each project sponsor. Use extra pages as
necessary. Enter the number of households served and the amount of HOPWA
funds expended during the operating year for the activities listed
below.

  -------------- --------------------------------- -------------------------- -----------------
  **Housing                                        **Number of                **Total HOPWA
  Assistance                                       [Households]{.underline}   Funds Expended
  Categories**                                     Receiving HOPWA Assistance during Operating
                                                   from this project          Year by this
                                                   sponsor**                  project sponsor**

  a\.            Tenant-based rental assistance                                    
                 (TBRA)                                                       

  b\.            Rental Assistance (RA) program                                    
                 using a reduced subsidy (shallow                             
                 rent or partial rent), [as                                   
                 approved in grant                                            
                 agreement]{.underline}                                       

  c\.            **Total RA Housing Assistance                                     
                 (total a + b)**                                              

  **Supportive                                                                
  Services                                                                    
  Provided by                                                                 
  This Project                                                                
  Sponsor Agency                                                              
  to Households                                                               
  Receiving                                                                   
  Tenant-based                                                                
  Rental                                                                      
  Assistance**                                                                

  e\.            **Total TBRA Supportive Services                                  
                 (unduplicated) provided by this                              
                 project sponsor**                                            
  -------------- --------------------------------- -------------------------- -----------------

***Program Outcomes:*** *TBRA is considered permanent affordable housing
and when provided with other appropriate support, such as access to
health-care and other mainstream human services, households are enabled
to establish and maintain stable living arrangements.*

**2. Short-term Rent, Mortgage and Utility Assistance (STRMU)**: For
project sponsors that provided Short-term Rent, Mortgage and Utility
Assistance using HOPWA funds during the Operating Year indicated in Part
3, please provide the following detailed information. Please fill out a
separate chart [for each project sponsor]{.underline}. Use extra pages,
as necessary. Enter the number of households served and the amount of
HOPWA funds expended at any point during the operating year for the
activities listed below.

  -------------- ------------------------------- -------------------------- -----------------
  **Housing                                      **Number of                **Total HOPWA
  Assistance                                     [Households]{.underline}   Funds Expended
  Categories**                                   Receiving HOPWA Assistance during Operating
                                                 from this project          Year by this
                                                 sponsor**                  project sponsor**

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

  b\.            Of the above households                                         
                 assisted (line b), please                                  
                 provide the number of mortgage                             
                 payments                                                   

  **Supportive                                                              
  Services                                                                  
  Provided by                                                               
  This Project                                                              
  Sponsor Agency                                                            
  to Households                                                             
  Receiving                                                                 
  STRMU**                                                                   

  c\.            **Total STRMU Supportive                                        
                 Services (unduplicated)                                    
                 provided by this project                                   
                 sponsor**                                                  
  -------------- ------------------------------- -------------------------- -----------------

*Program Outcomes. STRMU is used to help stabilize clients in current
housing and provide time to develop a permanent housing plan, if needed,
to connect to longer term support (before the end of the short-term
limits on assistance). Continued reliance on short-term assistance for
the same household would not represent a stable living situation.*

**Part 3: Project Sponsor Information**

**B. Facility-based Housing Assistance**

Please fill out this section for all facility or project-based housing
assistance activities. For project sponsors that provided facility-based
housing assistance using HOPWA funds during this Operating Year please
provide the following detailed information [for each
facility]{.underline}. Fill out one PART 3 B. section [for each housing
facility]{.underline} operated using HOPWA dollars. Use extra pages as
necessary. If no expenditures were made 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 back of this section of the form.

**1 a). Capital Development of Projects Only (For Each Facility
developed)**

+---+--------+---------+----------+-----------------------------------+
| * |        | **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:       Not yet       |
| \ | supp   |         |          | providing services                |
| . | ortive |         |          |                                   |
|   | se     |         |          |                                   |
|   | rvices |         |          |                                   |
|   | began: |         |          |                                   |
+---+--------+---------+----------+-----------------------------------+
| e | Number |         |          |      HOPWA-funded units           |
| \ | of     |         |          |      Total 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? |         |          |                                   |
+---+--------+---------+----------+-----------------------------------+

**1 b). Capital Development of Projects Only**: For units entered above
(1 a) please list the number of HOPWA units that fulfill the following
criteria.

+----------+--------+-------+---------+-------+-------+------------+
|          | Desi   | Desig | Intern  | E     | 504   | Years of   |
|          | gnated | nated | ational | nergy | Acces | aff        |
|          | for    | for   | B       | -Star | sible | ordability |
|          | the    | a     | uilding | Comp  |       |            |
|          | chron  | ssist | Code    | liant |       | (IN YEARS) |
|          | ically | the   | Co      |       |       |            |
|          | ho     | hom   | mpliant |       |       |            |
|          | meless | eless |         |       |       |            |
+----------+--------+-------+---------+-------+-------+------------+
| Rental   |        |       |         |       |       |            |
| units    |        |       |         |       |       |            |
| con      |        |       |         |       |       |            |
| structed |        |       |         |       |       |            |
| (new)    |        |       |         |       |       |            |
| and/or   |        |       |         |       |       |            |
| acquired |        |       |         |       |       |            |
| with or  |        |       |         |       |       |            |
| without  |        |       |         |       |       |            |
| rehab    |        |       |         |       |       |            |
+----------+--------+-------+---------+-------+-------+------------+
| Rental   |        |       |         |       |       |            |
| units    |        |       |         |       |       |            |
| rehabbed |        |       |         |       |       |            |
+----------+--------+-------+---------+-------+-------+------------+
| Homeo    |        |       |         |       |       |            |
| wnership |        |       |         |       |       |            |
| units    |        |       |         |       |       |            |
| con      |        |       |         |       |       |            |
| structed |        |       |         |       |       |            |
| (if      |        |       |         |       |       |            |
| a        |        |       |         |       |       |            |
| pproved) |        |       |         |       |       |            |
+----------+--------+-------+---------+-------+-------+------------+

**2. Units assisted in types of housing facility (for each housing
facility assisted).** For each type of housing facility, indicate the
number of housing units in the facility, categorized by the number of
bedrooms per unit. Please note, this number may not equal the total
number of households served.

  ----------- ------------------------ ------------- -------- ----------- -------- -------- ------------
  **Type of                            **Total                                              
  housing                              Number of                                            
  facility                             Units                                                
  operated by                          Operated in                                          
  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\.         Short-term or                                                                      
              transitional supported                                                        
              housing facility                                                              

  d\.         Units leased by project                                                            
              sponsor/Project-based                                                         
              rental assistance units                                                       

  e\.         Other housing facility                                                             
              (specify):                                                                    
  ----------- ------------------------ ------------- -------- ----------- -------- -------- ------------

> **3. Facility-Based Housing Expenditures.** Enter the total number of
> households (such as a single participant) served in operating
> facilities and the amount of HOPWA funds expended during the operating
> year for the activities listed below. If the development involved more
> than one activity then indicate the adjustment for duplication, while
> showing the expenditures directly made for each the activities. Please
> refer to the definitions section for clarification on terminology.

  ---------------- ------------------------------- -------------------------- -------------------
  **Housing                                        **Number of                **Total HOPWA Funds
  Assistance                                       [Households]{.underline}   Expended during
  Categories**                                     Receiving HOPWA Assistance Operating Year by
                                                   from this project          this project
                                                   sponsor**                  sponsor**

  a\.              Leasing costs                                                   

  b\.              Operating Costs                                                 

  c\.              Project-Based Rental Assistance                                 
                   (PBRA) or Rental subsidy for a                             
                   unit owned (or leased) by                                  
                   another agency                                             

  d\.              Other, if approved (Specify):                                   

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

  f\.              **Total Facility-Based Housing                                  
                   Assistance**                                               

  **Supportive                                                                
  Services                                                                    
  Provided by This                                                            
  Project Sponsor                                                             
  Agency to                                                                   
  Households                                                                  
  Receiving                                                                   
  Facility-based                                                              
  Rental                                                                      
  Assistance**                                                                

  g\.              **Total Facility-Based                                          
                   Supportive Services                                        
                   (unduplicated) provided by this                            
                   project sponsor**                                          
  ---------------- ------------------------------- -------------------------- -------------------

> *Program Outcomes. Facility-based support may be considered permanent
> supportive housing when provided with other appropriate on-site
> support, such as assistance with daily living activities or other
> needed support. Residents also benefit from improved access to
> health-care and other mainstream human services. Facilities may also
> be designed for short-term or transitional efforts to help individuals
> better prepare to establish and maintain stable living arrangements.*
>
> *To avoid duplication report only households receiving supportive
> services (in conjunction with facility-based housing assistance)*

*once.*

**Part 3: Project Sponsor Information**

**HOPWA Housing Project Certification of Continued Usage**

**For Facility-Based Stewardship Units ONLY**

Grantees that received Housing Opportunities for Persons with AIDS
(HOPWA) funding for new construction, acquisition, or substantial
rehabilitation are required to operate their facilities for HOPWA
eligible individuals for at least ten years, or at least three years, if
non-substantial rehabilitation funds were used. Stewardship begins once
the facility is put into operation.

+----------------------+---------------+---------------+--------------+
| **HUD Grant          |               | **Operating   |              |
| Number(s)**          |               | 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**  |              |
|                      |               |               |              |
|                      |               | **     **     |              |
+----------------------+---------------+---------------+--------------+
| **Housing            | **Number of   | **Total       | **Amount of  |
| Assistance**         | Units         | Amount of     | Leveraging   |
|                      | Receiving     | HOPWA Funds   | from Other   |
|                      | Housing       | Expended      | Sources Used |
|                      | Assistance    | during        | during the   |
|                      | with HOPWA    | Operating     | Operating    |
|                      | funds**       | Year**        | Year**       |
+----------------------+---------------+---------------+--------------+
| **Stewardship units  |               | []{.mark}     |              |
| (developed with      |               |               |              |
| HOPWA funds but no   |               |               |              |
| current operations   |               |               |              |
| or other HOPWA       |               |               |              |
| costs) subject to 3- |               |               |              |
| or 10- year use      |               |               |              |
| periods**            |               |               |              |
+----------------------+---------------+---------------+--------------+
| **For Project        |               |               |              |
| Sites\--Name of      |               |               |              |
| HOPWA-funded         |               |               |              |
| project**            |               |               |              |
+----------------------+---------------+---------------+--------------+
| **Site Information:  |               |               |              |
| Project Zip Code(s)  |               |               |              |
| and Congressional    |               |               |              |
| District(s)**        |               |               |              |
+----------------------+---------------+---------------+--------------+
| **Is the address of  | *Yes, protect |               |              |
| the project site     | information;  |               |              |
| confidential?**      | do not list.* |               |              |
|                      |               |               |              |
|                      | *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)*                         |                                   |
|                                   |                                   |
| **     **                         |                                   |
+-----------------------------------+-----------------------------------+

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 which had been acquired, rehabilitated or constructed and
developed in part with HOPWA funds.

**Part 3: Project Sponsor Information**

**C. Supportive Services Only Programs**

**1. Supportive Services.** Complete this section for project sponsors
providing supportive services [only]{.underline}\* using HOPWA funds
during the operating year, i.e., to households whose housing needs are
being met through [Non]{.underline}- HOPWA housing assistance.

+---+-------------------------------------+------------+---------------+
| * |                                     | **Number   | **Total HOPWA |
| * |                                     | of         | Funds         |
| S |                                     | [Hou       | Expended      |
| u |                                     | seholds]{. | during the    |
| p |                                     | underline} | Operating     |
| p |                                     | Receiving  | year by this  |
| o |                                     | HOPWA      | project       |
| r |                                     | Assistance | sponsor**     |
| t |                                     | from this  |               |
| i |                                     | project    |               |
| v |                                     | sponsor**  |               |
| e |                                     |            |               |
| S |                                     |            |               |
| e |                                     |            |               |
| r |                                     |            |               |
| v |                                     |            |               |
| i |                                     |            |               |
| c |                                     |            |               |
| e |                                     |            |               |
| s |                                     |            |               |
| p |                                     |            |               |
| r |                                     |            |               |
| o |                                     |            |               |
| v |                                     |            |               |
| i |                                     |            |               |
| d |                                     |            |               |
| e |                                     |            |               |
| d |                                     |            |               |
| b |                                     |            |               |
| y |                                     |            |               |
| P |                                     |            |               |
| r |                                     |            |               |
| o |                                     |            |               |
| j |                                     |            |               |
| e |                                     |            |               |
| c |                                     |            |               |
| t |                                     |            |               |
| S |                                     |            |               |
| p |                                     |            |               |
| o |                                     |            |               |
| n |                                     |            |               |
| s |                                     |            |               |
| o |                                     |            |               |
| r |                                     |            |               |
| A |                                     |            |               |
| g |                                     |            |               |
| e |                                     |            |               |
| n |                                     |            |               |
| c |                                     |            |               |
| y |                                     |            |               |
| * |                                     |            |               |
| * |                                     |            |               |
+---+-------------------------------------+------------+---------------+
| a | **Total Households receiving        |            |               |
| \ | Supportive Services Only            |            |               |
| . | (unduplicated)\***                  |            |               |
+---+-------------------------------------+------------+---------------+
| * |                                     |            |               |
| * |                                     |            |               |
| B |                                     |            |               |
| r |                                     |            |               |
| e |                                     |            |               |
| a |                                     |            |               |
| k |                                     |            |               |
| - |                                     |            |               |
| o |                                     |            |               |
| u |                                     |            |               |
| t |                                     |            |               |
| o |                                     |            |               |
| f |                                     |            |               |
| S |                                     |            |               |
| u |                                     |            |               |
| p |                                     |            |               |
| p |                                     |            |               |
| o |                                     |            |               |
| r |                                     |            |               |
| t |                                     |            |               |
| i |                                     |            |               |
| v |                                     |            |               |
| e |                                     |            |               |
| S |                                     |            |               |
| e |                                     |            |               |
| r |                                     |            |               |
| v |                                     |            |               |
| i |                                     |            |               |
| c |                                     |            |               |
| e |                                     |            |               |
| s |                                     |            |               |
| P |                                     |            |               |
| r |                                     |            |               |
| o |                                     |            |               |
| v |                                     |            |               |
| i |                                     |            |               |
| d |                                     |            |               |
| e |                                     |            |               |
| d |                                     |            |               |
| b |                                     |            |               |
| y |                                     |            |               |
| T |                                     |            |               |
| h |                                     |            |               |
| i |                                     |            |               |
| s |                                     |            |               |
| P |                                     |            |               |
| r |                                     |            |               |
| o |                                     |            |               |
| j |                                     |            |               |
| e |                                     |            |               |
| c |                                     |            |               |
| t |                                     |            |               |
| S |                                     |            |               |
| p |                                     |            |               |
| o |                                     |            |               |
| n |                                     |            |               |
| s |                                     |            |               |
| o |                                     |            |               |
| r |                                     |            |               |
| A |                                     |            |               |
| g |                                     |            |               |
| e |                                     |            |               |
| n |                                     |            |               |
| c |                                     |            |               |
| y |                                     |            |               |
| * |                                     |            |               |
| * |                                     |            |               |
+---+-------------------------------------+------------+---------------+
| b | Adult day care and personal         |            |               |
| \ | assistance                          |            |               |
| . |                                     |            |               |
+---+-------------------------------------+------------+---------------+
| c | Alcohol and drug abuse services     |            |               |
| \ |                                     |            |               |
| . |                                     |            |               |
+---+-------------------------------------+------------+---------------+
| d | Case management/client advocacy/    |            |               |
| \ | access to benefits & services       |            |               |
| . |                                     |            |               |
+---+-------------------------------------+------------+---------------+
| e | Child care and other child services |            |               |
| \ |                                     |            |               |
| . |                                     |            |               |
+---+-------------------------------------+------------+---------------+
| f | Education                           |            |               |
| \ |                                     |            |               |
| . |                                     |            |               |
+---+-------------------------------------+------------+---------------+
| g | Employment assistance and training  |            |               |
| \ |                                     |            |               |
| . |                                     |            |               |
+---+-------------------------------------+------------+---------------+
| h | Health/medical/intensive care       |            |               |
| \ | services, if approved               |            |               |
| . |                                     |            |               |
|   | Note: Client records must conform   |            |               |
|   | with 24 CFR §574.310                |            |               |
+---+-------------------------------------+------------+---------------+
| i | Legal services                      |            |               |
| \ |                                     |            |               |
| . |                                     |            |               |
+---+-------------------------------------+------------+---------------+
| j | Life skills management (outside of  |            |               |
| \ | case management)                    |            |               |
| . |                                     |            |               |
+---+-------------------------------------+------------+---------------+
| k | Meals/nutritional services          |            |               |
| \ |                                     |            |               |
| . |                                     |            |               |
+---+-------------------------------------+------------+---------------+
| l | Mental health services              |            |               |
| \ |                                     |            |               |
| . |                                     |            |               |
+---+-------------------------------------+------------+---------------+
| m | Outreach                            |            |               |
| \ |                                     |            |               |
| . |                                     |            |               |
+---+-------------------------------------+------------+---------------+
| n | Transportation                      |            |               |
| \ |                                     |            |               |
| . |                                     |            |               |
+---+-------------------------------------+------------+---------------+
| o | Other (only if HUD-approved):       |            |               |
| \ |                                     |            |               |
| . |                                     |            |               |
+---+-------------------------------------+------------+---------------+
| * |                                     |            |               |
| * |                                     |            |               |
| H |                                     |            |               |
| 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 |                                     |            |               |
| S |                                     |            |               |
| e |                                     |            |               |
| r |                                     |            |               |
| v |                                     |            |               |
| i |                                     |            |               |
| c |                                     |            |               |
| e |                                     |            |               |
| s |                                     |            |               |
| * |                                     |            |               |
| * |                                     |            |               |
+---+-------------------------------------+------------+---------------+
| p | Housing Information Services        |            |               |
| \ |                                     |            |               |
| . |                                     |            |               |
+---+-------------------------------------+------------+---------------+
| q | Permanent Housing Placement         |            |               |
| \ | Services                            |            |               |
| . |                                     |            |               |
+---+-------------------------------------+------------+---------------+
| r | **Total Housing Placement           |            |               |
| \ | Assistance**                        |            |               |
| . |                                     |            |               |
+---+-------------------------------------+------------+---------------+
| * |                                     |            |               |
| * |                                     |            |               |
| A |                                     |            |               |
| d |                                     |            |               |
| m |                                     |            |               |
| i |                                     |            |               |
| n |                                     |            |               |
| i |                                     |            |               |
| s |                                     |            |               |
| t |                                     |            |               |
| r |                                     |            |               |
| a |                                     |            |               |
| t |                                     |            |               |
| i |                                     |            |               |
| o |                                     |            |               |
| n |                                     |            |               |
| & |                                     |            |               |
| M |                                     |            |               |
| a |                                     |            |               |
| n |                                     |            |               |
| a |                                     |            |               |
| g |                                     |            |               |
| e |                                     |            |               |
| m |                                     |            |               |
| e |                                     |            |               |
| n |                                     |            |               |
| t |                                     |            |               |
| S |                                     |            |               |
| e |                                     |            |               |
| r |                                     |            |               |
| v |                                     |            |               |
| i |                                     |            |               |
| c |                                     |            |               |
| e |                                     |            |               |
| s |                                     |            |               |
| * |                                     |            |               |
| * |                                     |            |               |
+---+-------------------------------------+------------+---------------+
| s | Resource Identification to          |            |               |
| \ | establish, coordinate and develop   |            |               |
| . | housing assistance resources        |            |               |
+---+-------------------------------------+------------+---------------+
| t | Project Outcomes/Program            |            |               |
|   | Evaluation\                         |            |               |
|   | (if approved in a grant agreement)  |            |               |
+---+-------------------------------------+------------+---------------+
| u | Project Sponsor Administration      |            |               |
| \ | (maximum 7% of subcontract)         |            |               |
| . |                                     |            |               |
+---+-------------------------------------+------------+---------------+
| v | Other Activity (if approved in      |            |               |
| \ | grant agreement) Specify:           |            |               |
| . |                                     |            |               |
+---+-------------------------------------+------------+---------------+
| w | **Total Administration & Management |            |               |
| \ | Services**                          |            |               |
| . |                                     |            |               |
+---+-------------------------------------+------------+---------------+
| * |                                     |            |               |
| * |                                     |            |               |
| T |                                     |            |               |
| o |                                     |            |               |
| t |                                     |            |               |
| a |                                     |            |               |
| l |                                     |            |               |
| E |                                     |            |               |
| x |                                     |            |               |
| p |                                     |            |               |
| e |                                     |            |               |
| n |                                     |            |               |
| d |                                     |            |               |
| e |                                     |            |               |
| d |                                     |            |               |
| * |                                     |            |               |
| * |                                     |            |               |
+---+-------------------------------------+------------+---------------+
| x | **Total HOPWA Expenditures (sum of  |            | **     **     |
| \ | items a + r + w)**                  |            |               |
| . |                                     |            |               |
+---+-------------------------------------+------------+---------------+

**Part 4: Appendix**

**Worksheet on Determining HOPWA Outcomes and Connections with HMIS**

**Background on HOPWA Housing Stability Codes**

**Short-term Housing**

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).

2 = Temporary housing - moved in with family/friends or other short-term
arrangement, such as Ryan White subsidy, transitional housing for
homeless, and temporary placement in institution (e.g., hospital,
psychiatric hospital or other psychiatric facility, substance abuse
treatment facility or detox center). \* *STRMU assistance is considered
short-term housing assistance. Refer to outcome indicators below to
correctly categorize households*. *STRMU is considered unstable, if
there is a reasonable expectation that additional support is needed.*

**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, hospital).

**Life Events**

7 = Jail /prison.

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

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

**OUTCOME ASSESSED:** The HOPWA assisted households were enabled to
establish and/or better maintain a stable living environment in housing
that is safe, decent, and sanitary, and to reduce their risks of
homelessness, and improve access to HIV treatment and other health care
increases through the use of annual resources with the goal that this
reaches 80 percent by 2008.

**OUTCOME INDICATOR** is the total as follows:

a\. for STRMU assistance: **Stable Housing** 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 private housing arrangements
(as this is a time-limited form of housing support) as shown as items:
3, 4, 5, and 6. **Unstable Situations** 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 additional support
will be needed to maintain housing arrangements in the next year. Report
under items 1, 2, 7, and 8.

b\. for TBRA: **Stable Housing** those is the sum of the number of
households who (i) remain in the housing and (ii) those who left the
assistance as shown as items: 3, 4, 5,and 6. **Unstable Situations** is
the sum of numbers reported under items 1, 2, 7 and 8.

c\. for Facility-based forms of housing assistance: **Stable Housing**
is the sum of the number of households who (i) remain in the housing and
(ii) those who left the assistance as shown as items: 3, 4, 5, and 6.
**Unstable Situations** is the sum of numbers reported under items 1, 2,
7, and 8.

**Worksheet to Determine Percentage of Clients in Stable Housing.**

+-------------------+-----------------+----------------+---------------+
| **Type of Housing | **\[1\] Number  | **\[2\] Number | **\[3\]       |
| Assistance**      | in stable       | in unstable    | Percent       |
|                   | housing**       | situations**   | Stable/total  |
|                   |                 |                | \[#1/(#1+     |
|                   |                 |                | #2)\]**       |
+-------------------+-----------------+----------------+---------------+
| Tenant-based      | (# remaining in | (1+2+7+8=#)    |               |
| Rental Assistance | program plus    |                |               |
|                   | 3+4+5+6=#)      |                |               |
|                   |                 |                |               |
+-------------------+-----------------+----------------+---------------+
| Facility-based    | (# remaining in | (1+2+7+8=#)    |               |
| Housing           | program plus    |                |               |
| Assistance        | 3+4+5+6=#)      |                |               |
|                   |                 |                |               |
+-------------------+-----------------+----------------+---------------+
| Short-term Rent,  | (3+4+5+6=#)     | (1+2+7+8=#)    |               |
| Mortgage, and     |                 |                |               |
| Utility           |                 |                |               |
| Assistance        |                 |                |               |
+-------------------+-----------------+----------------+---------------+
| Total HOPWA       |                 |                |               |
| Housing           |                 |                |               |
| Assistance        |                 |                |               |
+-------------------+-----------------+----------------+---------------+

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

+--------------------------+----------------------+--------------------+
| 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    |                    |
|                            | residency          |                    |
|                            |                    |                    |
|                            | 2=Had contact with |                    |
|                            | a case manager at  |                    |
|                            | least once in the  |                    |
|                            | last three months  |                    |
|                            |                    |                    |
|                            | 3=Had contact with |                    |
|                            | a primary health   |                    |
|                            | care provider at   |                    |
|                            | least once in the  |                    |
|                            | last three months  |                    |
|                            |                    |                    |
|                            | 4=Had medical      |                    |
|                            | insurance coverage |                    |
|                            |                    |                    |
|                            | 5=Obtained an      |                    |
|                            | income-producing   |                    |
|                            | job created by     |                    |
|                            | this project       |                    |
|                            | sponsor during the |                    |
|                            | year               |                    |
|                            |                    |                    |
|                            | 6=Received a       |                    |
|                            | successful         |                    |
|                            | referral to a job  |                    |
|                            | created outside    |                    |
|                            | this agency during |                    |
|                            | the year           |                    |
+----------------------------+--------------------+--------------------+