HUD 40110D CAPER Measuring Performance Outcomes

Housing Opportunities for Persons With AIDS (HOPWA) Program

Consolidated Annual Performance and

Evaluation Report (CAPER)

Measuring Performance Outcomes

OMB Number 2506-0133 Expiration Date xx/xx/xxxx

The HOPWA CAPER report for formula grantees provides annual information on program accomplishments in meeting the program’s performance outcome measure: maintain housing stability; improve access to care; and reduce the risk of homelessness for low-income persons and their families living with HIV/AIDS. This information is also covered under the Consolidated Plan Management Process (CPMP) report and includes Narrative Responses and Performance Charts required under the Consolidated Planning Regulations. The public reporting burden for the collection of information is estimated to average 45 hours per manual response, or less if an automated data collection and retrieval system is in use, along with 68 hours for record keeping, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Grantees are required to report on the activities undertaken only, thus there may be components of these reporting requirements that may not be applicable. This agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless that collection displays a valid OMB control number.

Overview. The Consolidated Annual Performance and Evaluation Report (CAPER) provides annual performance reporting on client outputs and outcomes that enables an assessment of grantee performance in achieving the housing stability outcome measure. The CAPER, in conjunction with the Integrated Disbursement Information System (IDIS), fulfills statutory and regulatory program reporting requirements and provides the grantee and HUD with the necessary information to assess the overall program performance and accomplishments against planned goals and objectives

HOPWA formula grantees are required to submit a CAPER, and complete annual performance information for all activities undertaken during each program year in the IDIS, demonstrating coordination with other Consolidated Plan resources. HUD uses the CAPER and IDIS data to obtain essential information on grant activities, project sponsors, housing sites, units and households, and beneficiaries (which includes racial and ethnic data on program participants). The Consolidated Plan Management Process tool (CPMP) provides an optional tool to integrate the reporting of HOPWA specific activities with other planning and reporting on Consolidated Plan activities.

The revisions contained within this edition are designed to accomplish the following: (1) provide for an assessment of unmet need; (2) streamline reporting sources and uses of leveraged resources; (3) differentiate client outcomes for temporary/short-term and permanent facility-based assistance; (4) clarify indicators for short-term efforts and reducing the risk of homelessness; and (5) clarify indicators for Access to Care and Support for this special needs population. In addition, grantees are requested to comply with the Federal Funding Accountability and Transparency Act 2006 (Public Law 109-282) which requires federal grant recipients to provide general information for all entities (including subrecipients) receiving $25,000+ in federal funds.

Table of Contents

PART 1: Executive Summary

1. Grantee Information

2. Project Sponsor Information

3. Contractor(s) or Subcontractor(s) Information

A. Grantee and Community Overview

B. Annual Performance under the Action Plan

C. Barriers or Trends Overview

D. Assessment of Unmet Housing Needs

PART 2: Sources of Leveraging

PART 3: Accomplishment Data

PART 4: Summary of Performance Outcomes

1. Housing Stability: Permanent Housing and Related Facilities

2. Prevention of Homelessness: Short-Term Housing Payments

3. Access to Care and Support: Housing Assistance with Supportive Services

PART 5: Worksheet - Determining Housing Stability Outcomes

PART 6: Certification of Continued Use for HOPWA Facility-Based Stewardship Units (Only)

Continued Use Periods. Grantees that use HOPWA funds 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, the grantee must submit an Annual Certification of Continued Project Operation throughout the required use periods. This certification is included in Part 5 in CAPER.

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

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

Definitions: Facility-Based Housing Assistance: All HOPWA housing expenditures which provide support to facilities, including community residences, SRO dwellings, short-term or transitional facilities, project-based units, master leased units, scattered site units leased by the organization, and other housing facilities approved by HUD.

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

Housing Assistance Total: The non-duplicated number of households receiving housing subsidies and residing in units of facilities that were dedicated to persons living with HIV/AIDS and their families that were supported with HOPWA or leveraged funds during this operating year.

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

Leveraged Funds: The amount of funds expended during the operating year from non-HOPWA federal, state, local, and private sources by grantees or sponsors in dedicating assistance to this client population. Leveraged funds or other assistance used directly in HOPWA program delivery.

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

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

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 rental costs).

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

Short-Term Rent, Mortgage and Utility Payments (STRMU): Subsidy or payments subject to the 21-week limited time period to prevent the homelessness of a household (e.g., HOPWA short-term rent, mortgage and utility payments).

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

Tenant-Based Rental Assistance: (TBRA): An on-going rental housing subsidy for units leased by the client, where the amount is determined based in part on household income and rent costs. Project-based costs are considered facility-based expenditures.

Total by Type of Housing Assistance/Services: The non-duplicated households assisted in units by type of housing assistance dedicated to persons living with HIV/AIDS and their families or services provided and that were supported with HOPWA and leveraged funds during the operating year

Housing Opportunities for Persons with AIDS (HOPWA)

Consolidated Annual Performance and Evaluation Report -

Measuring Performance Outcomes

(OMB Number 2506-0133 Expiration Date xx/xx/xxxx)

Part 1: Grantee Executive Summary

As applicable, complete the charts below followed by the submission of a written narrative to questions A through C, and the completion of Chart D. Chart 1 requests general grantee information and Chart 2 is to be completed for each organization selected or designated as a project sponsor, as defined by CFR 574.3. In Chart 3, indicate each subrecipient organization with a contract/agreement of $25,000 or greater that assists grantees or project sponsors carrying out their activities. Agreements include: grants, subgrants, loans, awards, cooperative agreements, and other foams of financial assistance; and contracts, subcontracts, purchase orders, task orders, and delivery orders. These elements address requirements in the Federal Funding and Accountability and Transparency Act of 2006 (Public Law 109-282).

1. Grantee Information

HUD Grant Number      		Operating Year for this report From (mm/dd/yy)       To (mm/dd/yy)      
Grantee Name      
Business Address	     
City, County, State, Zip	     		     		     	     
Employer Identification Number (EIN) or Tax Identification Number (TIN)	     			DUN & Bradstreet Number (DUNs) if applicable      
Congressional District of Business Address	     
*Congressional District(s) of Primary Service Area(s)	                             
*Zip Code(s) of Primary Service Area(s)	                             
*City(ies) and County(ies) of Primary Service Area(s)	                             				                       
Organization’s Website Address      			Does your organization maintain a waiting list? Yes No If yes, explain in the narrative section how this list is administered.
Have you prepared any evaluation reports? If so, please indicate the location on an Internet site (url) or attach copy.      

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

2. Project Sponsor Information

In Chart 2, provide the following information for each organization designated or selected to serve as a project sponsor, as defined by CFR 574.3.

Project Sponsor Agency Name      		Parent Company Name, if applicable      
Name and Title of Contact at Project Sponsor Agency	     
Email Address	     
Business Address	     
City, County, State, Zip,	     			     			     	     
Phone Number (with area codes)	     				Fax Number (with area code)      
Employer Identification Number (EIN) or Tax Identification Number (TIN)	     				DUN & Bradstreet Number (DUNs) if applicable      
Congressional District of Business Location of Sponsor	     
Congressional District(s) of Primary Service Area(s)	     
Zip Code(s) of Primary Service Area(s)	     
City(ies) and County(ies) of Primary Service Area(s)	     					     
Total HOPWA contract amount for this Organization	     
Organization’s Website Address      			Does your organization maintain a waiting list? Yes No If yes, explain in the narrative section how this list is administered.
Is the sponsor a nonprofit organization? Yes No Please check if yes and a faith-based organization. Please check if yes and a grassroots organization.

3. Subrecipient Information

In Chart 3, provide the following information for each subrecipient with a contract/agreement of $25,000 or greater that assist the grantee or project sponsors to carry out their administrative or service delivery functions. Agreements include: grants, subgrants, loans, awards, cooperative agreements, and other forms of financial assistance; and contracts, subcontracts, purchase orders, task orders, and delivery orders. (Organizations listed may have contracts with project sponsors or other organizations beside the grantee.) These elements address requirements in the Federal Funding and Accountability and Transparency Act of 2006 (Public Law 109-282).

Subrecipient Name      			Parent Company (if applicable)      
Name and Title of Contact at Subrecipient	     
Email Address	     
Business Address	     
City, State, Zip, County	     	     		     		     
Phone Number (with area code)	     			Fax Number (with area code)      
Employer Identification Number (EIN) or Tax Identification Number (TIN)	     		DUN & Bradstreet Number (DUNs) if applicable      
North American Industry Classification System (NAICS) Code	     
Congressional District of Location	     
Congressional District of Primary Service Area	     
Zip Code of Primary Service Area(s)	                             
City(ies) and County(ies) of Primary Service Area(s)	                             				                       
Total HOPWA Contract Amount	     

A. Grantee and Community Overview

Provide a one to three page narrative summarizing major achievements and highlights that were proposed and completed during the program year. Include a brief description of the grant organization, area of service, the name(s) of the program contact(s), and an overview of the range/type of housing activities provided. This overview may be used for public information, including posting on HUD’s website. Note: Text fields are expandable.

     

B. Annual Performance under the Action Plan

Provide a narrative addressing each of the following four items:

1. Outputs Reported. Describe significant accomplishments or challenges in achieving the number of housing units supported and the number households assisted with HOPWA funds during this operating year compared to plans for this assistance, as approved in the Consolidated Plan/Action Plan. Describe how HOPWA funds were distributed during your program year among different categories of housing and geographic areas to address needs throughout the grant service area, consistent with approved plans.

2. Outcomes Assessed. Assess program goals against actual client outcomes for achieving housing stability, reducing risks of homelessness, and improving access to care. If current year results are lower than the national program targets (80 percent of HOPWA clients maintain housing stability, avoid homelessness and access care), please describe the steps being taken to achieve the national outcome goal in next operating year. 

3. Coordination. Report on program coordination with other mainstream housing and supportive services resources, including the use of committed leveraging from other public and private sources that helped to address needs for eligible persons identified in the Consolidated Plan/Strategic Plan.

4. Technical Assistance. Describe any program technical assistance needs and how they would benefit program beneficiaries.

     

C. Barriers and Trends Overview

Provide a narrative addressing items 1 through 3. Explain how barriers and trends affected your program’s ability to achieve the objectives and outcomes discussed in the previous section.

1. Describe any barriers (including regulatory and non-regulatory) encountered, actions taken in response to barriers, and recommendations for program improvement. Provide an explanation for each barrier selected.

HOPWA/HUD Regulations Planning Housing Availability Rent Determination and Fair Market Rents

Discrimination/Confidentiality Multiple Diagnoses Eligibility Technical Assistance or Training

Supportive Services Credit History Rental History Criminal Justice History

Housing Affordability Other, please explain further

2. Describe any trends in the community that may affect the way in which the needs of persons living with HIV/AIDS are being addressed, and provide any other information important to the future provision of services to this population.

3. Identify any evaluations, studies, or other assessments of the HOPWA program that are available to the public.

     

D. Unmet Housing Needs: An Assessment of Unmet Housing Needs

In Chart 1, provide an assessment of the number of HOPWA-eligible households that require housing assistance but are not currently served by HOPWA in this service area.

In Line 1, report the total unmet need of the geographical service area, as reported in Unmet Needs for Persons with HIV/AIDS, Table 1B of the Consolidated or Annual Plan(s), or as reported under HOPWA worksheet in the Needs Workbook of the Consolidated Planning Management Process (CPMP) tool. Note: Report most current data available, through Consolidated or Annual Plan(s), and account for local housing issues, or changes in HIV/AIDS cases, by using combination of one or more of the sources in Chart 2.

In Rows a through c, enter the number of HOPWA-eligible households by type of housing assistance whose housing needs are not met. For an approximate breakdown of overall unmet need by type of housing assistance refer to the Consolidated or Annual Plan (s), CPMP tool or local distribution of funds.

1. Assessment of Unmet Need for HOPWA-eligible Households

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

2. Recommended Data Sources for Assessing Unmet Need (check all sources used)

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

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

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

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

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

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

housing

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

End of PART 1

PART 2: Sources of Leveraging

Report the source(s) of cash or in-kind leveraged federal, state, local or private resources identified in the Consolidated or Annual Plan and used in the delivery of the HOPWA program and the amount of leveraged dollars.

[1] Sources of Leveraging		Total Amount of Leveraged Dollars (for this operating year)
		[2] Housing Assistance	[3] Supportive Services and other non-direct housing costs
1.	Program Income	=      	=      
2.	Federal government (please specify):	=      	=      
	     	=      	=      
	     	=      	=      
	     	=      	=      
3.	State government (please specify)	=      	=      
	     	=      	=      
	     	=      	=      
	     	=      	=      
4.	Local government (please specify)	=      	=      
	     	=      	=      
	     	=      	=      
	     	=      	=      
5.	Foundations and other private cash resources (please specify)	=      	=      
	     	=      	=      
	     	=      	=      
	     	=      	=      
6.	In-kind Resources	=      	=      
7.	Resident rent payments in Rental, Facilities, and Leased Units	=      	=      
8.	Grantee/project sponsor (Agency) cash	=      	=      
9.	TOTAL (Sum of 1-7)	=      	=      

End of PART 2

PART 3: Accomplishment Data - Planned Goal and Actual Outputs

In Chart 1, enter performance information (goals and actual outputs) for all activities undertaken during the operating year supported with HOPWA funds. Performance is measured by the number of households and units of housing that were supported with HOPWA or other federal, state, local, or private funds for the purposes of providing housing assistance and support to persons living with HIV/AIDS and their families. Note: The total households assisted with HOPWA funds and reported in PART 3 of the CAPER should be the same as reported in the annual year-end IDIS data, and goals reported should be consistent with the Annual Plan information. Any discrepancies or deviations should be explained in the narrative section of PART 1.

1. HOPWA Performance Planned Goal and Actual Outputs

	HOPWA Performance Planned Goal and Actual			Output Households				Funding
				HOPWA Assistance		Non-HOPWA
				a.	b.	c.	d.	e.	f.
				Goal	Actual	Goal	Actual	HOPWA Budget	HOPWA Actual
	Housing Subsidy Assistance		Output Households
1.	Tenant-Based Rental Assistance
2a.	Households in permanent housing facilities that receive operating subsidies/leased units
2b.	Households in transitional/short-term housing facilities that receive operating subsidies/leased units
3a.	Households in permanent housing facilities developed with capital funds and placed in service during the program year
3b.	Households in transitional/short-term housing facilities developed with capital funds and placed in service during the program year
4.	Short-Term Rent, Mortgage and Utility Assistance
5.	Adjustments for duplication (subtract)
6.	Total Housing Subsidy Assistance
	Housing Development (Construction and Stewardship of facility based housing)			Output Units
7.	Facility-based units being developed with capital funding but not opened (show units of housing planned)
8.	Stewardship Units subject to 3 or 10 year use agreements
9	Total Housing Developed
	Supportive Services			Output Households
10a.	Supportive Services provided by project sponsors also delivering HOPWA housing assistance
10b.	Supportive Services provided by project sponsors serving households who have other housing arrangements
11.	Adjustment for duplication (subtract)
12.	Total Supportive Services
	Housing Placement Assistance Activities
13.	Housing Information Services
14.	Permanent Housing Placement Services
15.	Adjustment for duplication
16.	Total Housing Placement Assistance
	Grant Administration and Other Activities
17.	Resource Identification to establish, coordinate and develop housing assistance resources
18.	Technical Assistance (if approved in grant agreement)
19.	Grantee Administration (maximum 3% of total HOPWA grant)
20.	Project Sponsor Administration (maximum 7% of portion of HOPWA grant awarded)
	Total Expenditures for program year (Sum of rows 6, 9, 12, 16, and 20)

2. Listing of Supportive Services

Report on the use of HOPWA funds for all supportive services. In Rows 1 through 16, provide the (unduplicated) total of all households and expenditures for each type of supportive service for all project sponsors.

Supportive Services		Number of Households Receiving HOPWA Assistance	Amount of HOPWA Funds Expended
1.	Adult day care and personal assistance	   	   
2.	Alcohol and drug abuse services	   	   
3.	Case management/client advocacy/ access to benefits & services	   	   
4.	Child care and other child services	   	   
5.	Education	   	   
6.	Employment assistance and training	   	   
7.	Health/medical/intensive care services, if approved Note: Client records must conform with 24 CFR §574.310	   	   
8.	Legal services	   	   
9.	Life skills management (outside of case management)	   	   
10.	Meals/nutritional services	   	   
11.	Mental health services	   	   
12.	Outreach	   	   
13.	Transportation	   	   
14.	Other Activity (if approved in grant agreement). Specify:    	   	   
15.	Adjustment for Duplication (subtract)	   
16.	TOTAL Households receiving Supportive Services (unduplicated)	   	   

End of PART 3

Part 4: Summary of Performance Outcomes

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

Section 1. Housing Stability: Assessment of Client Outcomes on Maintaining Housing Stability (Permanent Housing and Related Facilities)

In Column 1, report the total number of eligible households that received HOPWA housing assistance, by type. In Column 2, enter the number of households continuing to access each type of housing assistance, the following year. In Column 3, report the housing status of all households that exited the program. Columns 2 (Number of Households Continuing) and 3 (Exited Households) summed will equal the total households reported in Column 1. Note: Refer to the housing stability codes that appear in Part 5: Worksheet - Determining Housing Stability Outcomes.

[A] Permanent Housing Assistance	[1] Total Number of Households Receiving Housing Assistance	[2] Assessment: Number of Households Continuing with this Housing (per plan or expectation for next year)		[3] Assessment: Number of Exited Households and Housing Status
Tenant-Based Rental Assistance	=      	=      		1 Emergency Shelter/Streets	=      
				2 Temporary Housing	=      
				3 Private Housing	=      
				4 Other HOPWA	=      
				5 Other Subsidy	=      
				6 Institution	=      
				7 Jail/Prison	=      
				8 Disconnected/Unknown	=      
				9 Death	=      
Permanent Supportive Housing Facilities/Units	=      	=      		1 Emergency Shelter/Streets	=      
				2 Temporary Housing	=      
				3 Private Housing	=      
				4 Other HOPWA	=      
				5 Other Subsidy	=      
				6 Institution	=      
				7 Jail/Prison	=      
				8 Disconnected/Unknown	=      
				9 Death	=      
[B] Transitional Housing Assistance	[1] Total Number of Households Receiving Housing Assistance	[2] Of the Total Number of Households Receiving Housing Assistance this Operating Year		[3] Assessment: Number of Exited Households and Housing Status
Transitional/Short-Term Supportive Facilities/Units	=      	Total number of households that will continue in residences: Total number of households whose tenure exceeded 24 months:	=       =      	1 Emergency Shelter/Streets	=      
				2 Temporary Housing	=      
				3 Private Housing	=      
				4 Other HOPWA	=      
				5 Other Subsidy	=      
				6 Institution	=      
				7 Jail/Prison	=      
				8 Disconnected/unknown	=      
				9 Death	=      

Section 2. Prevention of Homelessness: Assessment of Client Outcomes on Reduced Risks of Homelessness

(Short-Term Housing Assistance)

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

Assessment of Households receiving STRMU Assistance

[1] STRMU Housing Assistance	[2] Assessment of Housing Status		[3] HOPWA Client Outcomes
=      	Maintain Private Housing without subsidy (e.g. Assistance provided/completed and client is stable, not likely to seek additional support)	=      	Stable/Permanent Housing (PH)
	Other Private Housing without subsidy	=      
	Other HOPWA support (PH)	=      
	Other housing subsidy (PH)	=      
	Institution (e.g. residential and long-term care)	=      
	Likely to maintain current housing arrangements, with additional STRMU assistance	=      	Temporarily Stable, with Reduced Risk of Homelessness
	Transitional Facilities/Short-term (e.g. temporary or transitional arrangement)	=      
	Temporary/non-permanent Housing arrangement (e.g. gave up lease, and moved in with family or friends but expects to live there less than 90 days)	=      
	Emergency Shelter/street	=      	Unstable Arrangements
	Jail/Prison	=      
	Disconnected	=      
	Death	=      	Life Event
1a. Total number of households that received STRMU assistance in the prior operating year, that also received STRMU assistance in the current operating year.				=      
1b. Total number of those households that received STRMU assistance in the two (2 years ago) prior operating years, that also received STRMU assistance in the current operating year.				=      

Section 3. HOPWA Outcomes on Access to Care and Support

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

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

Categories of Services Accessed	Households Receiving Housing Assistance within the Operating Year	Outcome Indicator
1. Has a housing plan for maintaining or establishing stable on-going housing.	     	Support for Stable Housing
2. Has contact with case manager/benefits counselor consistent with the schedule specified in client’s individual service plan..	     	Access to Support
3. Had contact with a primary health care provider consistent with the schedule specified in client’s individual service plan,	     	Access to Health Care
4. Has accessed and can maintain medical insurance/assistance.	     	Access to Health Care
5. Successfully accessed or maintained qualification for sources of income.	     	Sources of Income

1B. Number of Households Obtaining Employment

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

Categories of Services Accessed	Number of Households that Obtained Employment	Outcome Indicator
Total number of households that obtained an income-producing job	     	Sources of Income

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

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

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

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

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

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

Categories of Services Accessed	Households Receiving HOPWA Assistance within the Operating Year	Outcome Indicator
1. Has a housing plan for maintaining or establishing stable on-going housing.	     	Support for Stable Housing
2. Successfully accessed or maintained qualification for sources of income.	     	Sources of Income
3. Had contact with a primary health care provider consistent with the schedule specified in clients individual service plan.	     	Access to Health Care
4. Has accessed and can maintain medical insurance/assistance.	     	Access to Health Care
5. Has contact with case manager, benefits counselor, or housing counselor consistent with the schedule specified in client’s individual service plan.	     	Access to Support

2B. Number of Households Obtaining Employment

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

Categories of Services Accessed	Number of Households that Obtained Employment	Outcome Indicator
Total number of households that obtained an income-producing job	     	Sources of Income

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

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

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

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

End of PART 4

PART 5: Worksheet - Determining Housing Stability Outcomes

1. This chart is designed to assess program results based on the information reported in Part 4.

Permanent Housing Assistance	Stable Housing (# of households remaining in program plus 3+4+5+6=#)	Temporary Housing (2)		Unstable Arrangements (1+7+8=#)	Life Event (9)
Tenant-Based Rental Assistance (TBRA)	     	     		     	     
Permanent Facility-based Housing Assistance/Units	     	     		     	     
Transitional/Short-Term Facility-based Housing Assistance/Units	     	     		     	     
Total Permanent HOPWA Housing Assistance	     	     		     	     
Reduced Risk of Homelessness: Short-Term Assistance	Stable/Permanent Housing	Temporarily Stable, with Reduced Risk of Homelessness		Unstable Arrangements	Life Events
Short-Term Rent, Mortgage, and Utility Assistance (STRMU)	     	     		     	     
Total HOPWA Housing Assistance	     	     		     	     

Background on HOPWA Housing Stability Codes

Stable Permanent Housing/Ongoing Participation

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

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

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

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

Temporary Housing

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

Unstable Arrangements

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

7 = Jail /prison.

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

Life Event

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

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

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

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

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

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

End of PART 5

PART 6: Certification of Continued Usage for HOPWA Facility-Based Stewardship Units (ONLY)

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

1. General information

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

2. Number of Units and Leveraging

Housing Assistance	Number of Units Receiving Housing Assistance with HOPWA funds	Amount of Leveraging from Other Sources Used during the Operating Year
Stewardship units (developed with HOPWA funds but no current operations or other HOPWA costs) subject to 3 or 10 year use periods	     	     

3. Details of Project Site

Name of HOPWA-funded project site	     
Project Zip Code(s) and Congressional District(s)	     
Is the address of the project site confidential?	Yes, protect information; do not list. Not confidential; information can be made available to the public.
If the site address is not confidential, please provide the contact name, phone, email, and physical address, if different from business 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 above. I also certify that the grant is still serving the planned number of HOPWA-eligible households at this facility through leveraged resources and all other 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 Official      	Signature & Date (mm/dd/yy)      
Name & Title of Contact at Grantee Agency (person who can answer questions about the report and program)      	Contact Phone (with area code)      

End of PART 6

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Previous editions are obsolete form HUD-40110-D (Revised 8/2007)