HUD 40110c APR Measuring Performance Outcomes

Housing Opportunities for Persons With AIDS (HOPWA) Program

Annual Progress Report (APR)

Measuring Performance Outcomes

OMB Number 2506-0133 Expiration Date XX/XX/XXXX

The HOPWA APR report for competitively selected 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. The public reporting burden for the collection of information is estimated to average 70 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.

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

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

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

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

Table of Contents

PART 1. Grantee Summary

PART 2. Grantee Narrative and Performance Assessment

PART 3. Summary Overview of Grant Activities

A. Information on Individuals, Beneficiaries, and Households

B. Budget and Grant Sources for Leveraging

C. Performance and Expenditure Information

PART 4. Summary of Performance Outcomes

PART 5. Summary of Project Sponsor Information

A. Project Sponsor Information

B. Housing Assistance

C. Facility-based Housing Assistance

D. Supportive Services

E. Certification of Continued Use for HOPWA Facility-based

Stewardship Units (ONLY)

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

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

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

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

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

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

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

Definitions

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

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

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

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

Chronically Homeless Person: An unaccompanied homeless individual with a disabling condition who has either been continuously homeless for a year or more OR has had at least four episodes of homelessness in the past three years.” For this purpose, the term “homeless” means “a person sleeping in a place not meant for human habitation (e.g., living on the streets) or in an emergency homeless shelter.” This does not include doubled-up or overcrowding situations.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Housing Opportunities for Persons with AIDS (HOPWA)

Annual Progress Report – Measuring Performance Outcomes

PART 1: Grantee Summary

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

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

1. Grantee Information

HUD Grant Number      			Operating Year for this report From (mm/dd/yy)       To (mm/dd/yy)       Yr 1; Yr 2; Yr 3; ExtYr
Grantee Name      			Parent Company if applicable      
Type of HOPWA Grant Competitive Formula
Business Address	     
City, State, Zip, County	     			     	     		     
Employer Identification Number (EIN) or Tax Identification Number (TIN)	     		DUN & Bradstreet Number (DUNs) if applicable      
*Congressional District of Address	     
*Congressional District of Primary Service Area(s)	                             
*Zip Code of Primary Service Area(s)	                             
City(ies) and County(ies) of Primary Service Area(s)	                             					                       
Organization’s Website Address      		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 report? If so, please indicate its location on an Internet site (url) or attach copy.      		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.

I hereby certify that all the information stated herein, as well as any information provided in the accompaniment herewith, is true and accurate. Warning: HUD will refer for prosecution false claims and statements. Conviction may result in criminal and/or civil penalties. (18 U.S.C. 1001, 1010, 1012, 31 U.S.C. 3729, 3802)
Name and Title of Authorized Official      	Signature & Date (mm/dd/yy)      
Name and Title of Contact at Grantee Agency (person who can answer questions about the report and program)      	Email Address      
Phone Number (include area code)      	Fax Number (include area code)      

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

2. Subrecipient Information/Grantee Activities

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

Organization      			Parent Company (if applicable)      
Name and Title of Contact at Subrecipient Organization	     
Email Address	     
Business Address	     
City, State, Zip, County	     	     		     		     
Phone Number (include area code)	     			Fax Number (include 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	     

Part 2: Grantee Narrative and Performance Assessment

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

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

     

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

     

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

HOPWA/HUD Regulations Planning Housing Availability Rent Determination and Fair Market Rents Discrimination/Confidentiality Multiple Diagnoses Eligibility Technical Assistance or Training

Supportive Services Credit History Rental History Criminal Justice History

Housing Affordability Other, please explain further

     

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

     

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

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

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

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

1. Service Area:

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

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

1. Total number of households that have unmet housing needs	=      
From Item 1, identify the number of 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	=      

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

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

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

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

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

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

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

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

.

Part 3: Summary Overview of Grant Activities

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

Section 1. Individuals

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

a. Total HOPWA eligible individuals living with HIV/AIDS

Individuals Served with Housing Assistance	Total Number
Number of individuals with HIV/AIDS who received HOPWA housing assistance	 

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

Category	Veteran(s)	Chronically Homeless	Domestic Violence Survivor(s)
TOTAL HOPWA eligible individuals served with Housing Assistance	 	 	 

c. Prior Living Situation.

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

Category		Total HOPWA Eligible Individuals Served with Housing Assistance
1.	Continuing to receive HOPWA support from the prior operating year	 
New Individuals who received HOPWA Housing Assistance support during Operating Year
2.	Place not meant for human habitation (such as a vehicle, abandoned building, bus/train/subway station/airport, or outside)	 
3.	Emergency shelter (including hotel, motel, or campground paid for with emergency shelter voucher)	 
4.	Transitional housing for homeless persons	 
5.	Permanent housing for formerly homeless persons (such as Shelter Plus Care, SHP, or SRO Mod Rehab)	 
6.	Psychiatric hospital or other psychiatric facility	 
7.	Substance abuse treatment facility or detox center	 
8.	Hospital (non-psychiatric facility)	 
9.	Foster care home or foster care group home	 
10.	Jail, prison or juvenile detention facility	 
11.	Rented room, apartment, or house	 
12.	House you own	 
13.	Staying or living in someone else’s (family and friends) room, apartment, or house	 
14.	Hotel or motel paid for without emergency shelter voucher	 
15.	Other	 
16.	Don’t Know or Refused	 
17.	TOTAL (sum of items 1-16)	 

Section 2. Beneficiaries

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

a. Total Number of HOPWA Beneficiaries Served with Housing Assistance

Individuals and Families Served with Housing Assistance	Total Number
1. Number of individuals with HIV/AIDS who received HOPWA housing assistance (Chart a page 5)	 
2. Number of other persons residing with the above eligible individuals in HOPWA-assisted housing	 
3. TOTAL number of beneficiaries served with Housing Assistance (Rows 1 + 2)	 

b. Age and Gender

Category		Male	Female
1.	Under 18	 	 
2.	18 to 30 years	 	 
3.	31 to 50 years	 	 
4.	51 years and Older	 	 

c. Race and Ethnicity*

	Category	Total Beneficiaries Served with Housing Assistance	Total Beneficiaries also identified as Hispanic or Latino		Category	Total Beneficiaries Served with Housing Assistance	Total Beneficiaries also identified as Hispanic or Latino
1.	American Indian/ Alaskan Native	 	 	6.	American Indian/ Alaskan Native & White	 	 
2.	Asian	 	 	7.	Asian & White	 	 
3.	Black/African American	 	 	8.	Black/African American and White	 	 
4.	Native Hawaiian/Other Pacific Islander	 	 	9.	American Indian/ Alaskan Native & Black/African American	 	 
5.	White	 	 	10.	Other Multi-Racial	 	 

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

Section 3. Households

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

Percentage of Area Median Income		Households Served with Housing Assistance
1.	0-30% of area median income (extremely low)	 
2.	31-50% of area median income (very low)	 
3.	51-60% of area median income (low)	 
4.	61-80% of area median income (low)	 

Part 3: Summary Overview of Grant Activities

B. Budget and Grant Sources for Leveraging

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

1. Households Assisted with Leveraged Funds for Housing

[A] Housing Assistance Outputs	[1] Tenant-Based Rental Assistance (TBRA)	[2] Permanent Housing Facilities	[3] Transitional/ Short-term Housing Facilities	[4] Short-Term Assistance (STRMU)	[5] Number of Units in Facilities under Development
1. Total Households Assisted	     	     	     	     
2. Total Units					     

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

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

[1] Sources of Leveraging		Total Amount of Leveraged Dollars (for this operating year) as approved in grant application
		[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, Project-Based Units, and Facilities	=      	=      
8.	Grantee/project sponsor (Agency) cash	=      	=      
9.	TOTAL (Sum of 1-7)	=      	=      

Part 3: Summary Overview of Grant Activities

C. Performance and Expenditure Information

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

1. Performance and Expenditure Information by Activity Type

Housing Subsidy Assistance		[1] HOPWA Assistance Outputs: Households	[2] Amount of HOPWA Funds Expended
1.	Tenant-Based Rental Assistance	     	     
2a.	Households in permanent housing facilities that receive operating subsidies/leased units	     	     
2b.	Households in transitional/short-term facilities that receive operating subsidies	     	     
3a.	Households in permanent housing facilities developed with capital funds, and placed in service during the operating year	     	     
3b.	Households in transitional/short-term facilities developed with capital funds, and placed in service during the operating year	     	     
4.	Short-term Rent, Mortgage, and Utility Assistance	     	     
5.	Adjustment for duplication (subtract)	     
6.	TOTAL Housing Assistance	     	     
Housing Development (Construction and Stewardship of Facility-Based Housing)		[1] HOPWA Assistance Outputs: Units	[2] Amount of HOPWA Funds Expended
7.	Facility-Based units being developed with capital funding but not yet opened (identify units of housing planned)	     	     
8.	Stewardship units subject to 3- or 10- year use periods	     
9.	TOTAL Housing Development	     	     

Supportive Services		[1] HOPWA Assistance Outputs: Households	[2] Amount of HOPWA Funds Expended
10a.	Supportive Services provided by project sponsors also delivering HOPWA housing assistance (as reported in Part 5 D, 1a)	     	     
10b.	Supportive Services provided by project sponsors serving households who have other housing arrangements (as reported in Part 5, D, 1b)	     	     
11.	Adjustment for duplication (subtract)	     
12.	TOTAL Supportive Services	     	     
Housing Placement Assistance Activities		[1] HOPWA Assistance Outputs: Households	[2] Amount of HOPWA Funds Expended
13.	Housing Information Services	     	     
14.	Permanent Housing Placement Services	     	     
15.	Adjustment for duplication (subtract)	     
16.	TOTAL Housing Placement Assistance	     	     
Grant Administration and Other Activities		[1] HOPWA Assistance Outputs: Households	[2] Amount of HOPWA Funds Expended
17.	Resource Identification to establish, coordinate and develop housing assistance resources		     
18.	Technical Assistance (if approved in grant agreement)		     
19.	Project Outcomes/Program Evaluation (if approved in grant agreement)		     
20.	Grantee Administration (maximum 3% of total of HOPWA grant)		     
21.	Project Sponsor Administration (maximum 7% of portion of HOPWA grant awarded)		     
22.	Other Activity (if approved in grant agreement). Specify:      	     	     
23.	TOTAL Grant Administration and Other Activities	     	     
TOTAL Expended			[2] Amount of HOPWA Funds Expended
24.	TOTAL Expenditures (Sum of Rows 6, 9, 12, 16 & 23)		     

Part 4: Summary of Performance Outcomes

Housing Stability, Prevention of Homelessness, and Access to Care

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

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

(Permanent Housing and Facilities)

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

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

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

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

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

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 use local program name	MEDICARE Health Insurance Program, or use local program name
Veterans Affairs Medical Services	AIDS Drug Assistance Program (ADAP)
State Children’s Health Insurance Program (SCHIP), or use 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 receiving HOPWA-funded housing placement or case management services who have other housing arrangements that demonstrated improved access or maintained connections to care and support within the program year by: having a housing plan; having contact with a case manager/benefits counselor; visiting a primary health care provider; accessing medical insurance/assistance; and accessing or qualifying for income benefits. Note: For information on types and sources of income and medical insurance/assistance, refer to Charts 2C and 2D.

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. 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 clients 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

Chart 2B. Number of Households Obtaining Employment

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

Categories of Services Accessed	Number of Households 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

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

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

Part 5A: Summary of Project Sponsor Information

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

1. Project Sponsor Information

Project Sponsor Agency Name      		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 code)	     				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
Is the sponsor a nonprofit organization? Yes No Please check if yes and a faith-based organization. Please check if yes and a grassroots organization.

2. Subrecipient Information/Sponsor Activities

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

Subrecipient Name	     		Parent Company Name, if applicable      
Name and Title of Contact at Contractor/ Sub-contractor Agency	     
Email Address	     
Business Address	     
City, County, State, Zip	     	     				     	     
Phone Number (included area code)	     			Fax Number (include area code)      
Employer Identification Number (EIN) or Tax Identification Number (TIN)	     		Dun & Bradstreet (DUNs), if applicable      
North American Industry Classification System (NAICS) Code	     
Congressional District of Business Address	     
Congressional District of Primary Service Area	     
Zip Code(s) of Primary Service Area(s)	                             
City (ies) and County (ies) of Primary Service Area(s)	                             				                       
Total HOPWA Subcontract Amount for this Organization	     

Part 5: Summary of Project Sponsor Information

B. Housing Assistance

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

1. Tenant-Based Rental Assistance (TBRA)

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

Housing Assistance Categories (TBRA)		Number of Households Receiving HOPWA Assistance from Project Sponsor	Total HOPWA Funds Expended during Operating Year by Project Sponsor
a.	Tenant-based rental assistance (TBRA)	   	   
b.	Other Rental Assistance (RA) Programs (if approved in grant agreement)	   	   
c.	TOTAL Rental Housing Assistance (total a + b)	   	   

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

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

Housing Assistance Categories (STRMU)		Number of Households Receiving HOPWA Assistance from Project Sponsor	Total HOPWA Funds Expended during Operating Year by Project Sponsor
a.	Short-term mortgage, rent and/or utility assistance	   	   
b.	Of the above, total STRMU assistance to homeowners (mortgage and/or utility)	   	   

Part 5: Summary of Project Sponsor Information

C. Facility-based Housing Assistance

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

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

Type of Development		HOPWA Funds Expended	Non-HOPWA funds Expended	Type of Facility [Check only one box.]
New construction		$	$	Permanent housing
Rehabilitation		$	$	Short-term Shelter or Transitional housing
Acquisition		$	$	Supportive services only facility
a.	Purchase/lease of property:			Date (mm/dd/yy):      
b.	Rehabilitation/Construction Dates:			Date started:       Date Completed:      
c.	Operation dates:			Date residents began to occupy:       Not yet occupied
d.	Date supportive services began:			Date started:       Not yet providing services
e.	Number of units in the facility:			HOPWA-funded units =       Total Units =      
f.	Is a waiting list maintained for the facility?			Yes No If yes, number of participants on the list at the end of operating year      
g.	What is the address of the facility (if different from business address)?			     
h.	Is the address of the project site confidential?			Yes, protect information; do not publish list. No, can be made available to the public.

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

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

	Designated for the chronically homeless	Designated for assist the homeless	Energy-Star Compliant	504 Accessible	Years of affordability (IN YEARS)
Rental units constructed (new) and/or acquired with or without rehab	   	   	   	   	   
Rental units rehabbed	   	   	   	   	   
Homeownership units constructed (if approved)	   	   	   	   	   

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

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

a. Check one only.

Permanent Supportive Housing Facility/Units

Short-term Shelter or Transitional Supportive Housing Facility/Units

b. Type of Facility

Type of housing facility operated by the project sponsor		Total Number of Units Operated in the Operating Year Categorized by the Number of Bedrooms per Units
		SRO/0 bdrm	1 bdrm	2bdrm	3 bdrm	4 bdrm	5+bdrm
a.	Single room occupancy dwelling	   
b.	Community residence	   	   	   	   	   	   
c.	Project-based rental assistance units or leased units	   	   	   	   	   	   
d.	Other housing facility. Specify:	   	   	   	   	   	   

3. Housing Expenditures

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

Housing Assistance Categories		Number of Households Served with HOPWA Assistance from Project Sponsor	Total HOPWA Funds Expended during Operating Year by Project Sponsor
a.	Leasing Costs	   	   
b.	Operating Costs	   	   
c.	Project-Based Rental Assistance (PBRA) or other leased units	   	   
d.	Other Activity (if approved in grant agreement). Specify:    	   	   
e.	Adjustment to eliminate duplication (subtract)	   
f.	TOTAL Facility-Based Housing Assistance	   	   

Part 5: Summary of Project Sponsor Information

D. Supportive Services

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

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

a. Supportive Services are provided by project sponsors also delivering HOPWA housing assistance
or
b. Supportive Services by project sponsors serving households with other housing arrangements

2. Listing of Supportive Services provided by Project Sponsor Agency

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)	   	   
	Housing Placement Assistance Categories	Number of Households Receiving HOPWA Assistance	Amount of HOPWA funds Expended
17.	Housing Information Services	   	   
18.	Permanent Housing Placement Services	   	   
19.	Adjustment for duplication (subtract)	   
20.	TOTAL Housing Placement Assistance (unduplicated, sum of items 17 + 18)	   	   
	Grant Administration and Other Activities	Number of Households Receiving HOPWA Assistance	Amount of HOPWA funds Expended
21.	Resource Identification to establish, coordinate, and develop housing assistance resources		     
22.	Technical Assistance to Community Residences		     
23.	Project Outcomes/Program Evaluation (if approved)		     
24.	Project Sponsor Administration (maximum 7% of portion of HOPWA grant awarded)		     
25.	Other Activity (if approved in grant agreement) Specify:      	     	     
26.	TOTAL Administration and Other Activities	     	     
27.	TOTAL Expenditures (sum of items 16 + 20 +26)		     

Part 5: Summary of Project Sponsor Information

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

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

1. General information

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

2. Number of Units and Leveraging

Housing Assistance	Number of Units 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

Project Sites: Name of HOPWA-funded project	     
Site Information: 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 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 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 (include area code)      

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

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

Permanent Housing Assistance	Stable Housing (# 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.

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

Data Element	Response Category
2.1 Name	First Name Middle Name Last Name Suffix
Current Name
Other Name Used to Receive Services Previously
2.2 Social Security Number	1=Full SSN Reported 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 added to HMIS list)	1=American Indian or Alaskan Native 2=Asian 3=Black or African-American 4=Native Hawaiian or Other Pacific Islander 5=White	6= American Indian or Alaskan Native and White 7=Asian and White 8=Black or African-American and White 9=American Indian 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 Program Entry	1=Emergency shelter 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 Previous Place	1=One week or less 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 Permanent Address	1=Full Zip Code 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 Identification Number	A PIN must be 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 Identification Number	A Household ID 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 Benefits	1=Food stamps or 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 2=Housing placement 3=Material goods 4=Temporary financial aid 5=Transportation 6=Consumer assistance and protection 7=Criminal justice/legal services 8=Education 9=Health care	10=HIV/AIDS-related services 11=Mental health counseling 12=Substance abuse services 13=Employment 14=Case/care management 15=Day care 16=Personal enrichment 17=Outreach 18=Other

Data Element	Response Category
3.9 Housing Status end of operating year or Destination
Destination / Housing Outcome * (* this section rearranged to the HOPWA outcome focus from HMIS standards)	1 (Emergency Shelter)= Emergency shelter or potentially place not meant for habitation (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 2=Section 8 3=Shelter Plus Care 4=HOME program 5=Other subsidy	6=None 8=Don’t Know 9=Refused 10=HOPWA program
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 care and other support * (added to HMIS standards)	1. Has a housing plan for maintaining or establishing stable on-going housing 2. Has contact with case manager/benefits counselor consistent with the schedule specified in client’s individual service plan. 3. Had contact with a primary health care provider consistent with the schedule specified in client’s individual service plan. 4. Has accessed and can maintain medical insurance/assistance. 5. Successfully accessed or maintained qualification for sources of income.
EXTRA. HOPWA access to care and other support: Obtained Employment * (added to HMIS standards)	Total number of households that obtained an income-producing job

Previous editions are obsolete form HUD-40110-C (Revised XX/XX)