Other reason: _______________________________________________________________________________
FUNDING AGENCY PROGRAMS FUNDED BY THIS AGENCY Color in the box to indicate the funding agency. Color in the circle to indicate the program type. = = HUD Housing and Urban Development CoC Programs (Continuum of Care program or McKinney Vento programs) SHP Project (Supportive Housing) S+C Project (Shelter Plus Care) SRO Project (Moderate Rehabilitation/Single Room Occupancy) HUD Housing and Urban Development ESG Programs (“Emergency Solutions Grants”) Emergency Shelter Project Street Outreach Project Homeless Prevention / Re-Housing Project HUD Housing and Development HOPWA Program (Housing Opportunities for Persons with AIDS) US Dep’t Veterans Affairs (VA) DCHV Domiciliary Care for Homeless Veterans Project GPD and Per Diem Project SSVF Supportive Services for Veteran Families Project VHPD Veterans Homelessness Prevention Demonstration Project HUD and VA HUD and U.S. Dpt. of Veterans Affairs VASH Veterans Affairs Supportive Housing Project HHS, SAMHSA U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration PATH Programs Projects for Assistance in Transition from Homelessness HHS, ACF FYSB U.S. Department of Health and Human Services, Administration for Children and Families’, Family and Youth Services Bureau RHY Programs (Runaway and Homeless Youth) Transitional Living Project Maternal Group Home Project Street Outreach Project National Runaway Switchboard Project State – where funding originates from one of the federal groups above. If funding originates from one of the federal agencies listed fill in the circle next to that federal agency, so we know which questions to answer on the HMIS website. State – where funding originates at the state level - and the state report is likely to be unique. Program Type and Name: _________________________________________________
Non-Cash Benefits Assessment Questions IS THIS HOUSEHOLD RECEIVING ONGOING BENEFITS AS OF THE INFORMATION DATE? Yes No CDNK CR to provide IF NO – IF YES –Please indicate which of the following non-cash benefits have you received over the last 30 days Fill In If YES Source of non-cash benefit HOPWA only Approx Start Date m/d/yyyy HOPWA Only If no, explain Food stamps or money for food on a benefits card Monthly Amount of Benefit = $ ____________.00 All services full Client not eligible Applied: pending decision CR the benefit Benefit does not exist Unknown MEDICAID or State-Funded Equivalent, specify: ____________________ MEDICARE health insurance program AIDS Drug Assistance Program (ADAP) All services full Client not eligible Applied: pending decision CR the benefit Benefit does not exist Unknown COBRA Health Insurance Employer Provided Health Insurance Private Pay Health Insurance All services full Client not eligible Applied: pending decision CR the benefit Benefit does not exist Unknown Ryan White medical assistance Children’s Health Insurance Program (SCHIP) Veteran’s Administration Medical Services All services full Client not eligible Applied: pending decision CR the benefit Benefit does not exist Unknown Permanent Rental Assistance -Section 8, Public Housing, or other Temporary Rental Assistance All services full Client not eligible Applied: pending decision CR the benefit Benefit does not exist Unknown TANF child care services TANF transportation services Other TANF-Funded Services All services full Client not eligible Applied: pending decision CR the benefit Benefit does not exist Unknown WIC Nutrition Program for Infants, and Children All services full Client not eligible Applied: pending decision CR the benefit Benefit does not exist Unknown Other source (explain) _______________________________________ All services full Client not eligible Applied: pending decision CR the benefit Benefit does not exist Unknown