HUD 90006 Annual Reporting Form

Congregate Housing Services Program

Annual Reporting Form

U.S. Department of Housing
and Urban Development
Office of Housing
Federal Housing Commissioner

OMB Approval No. 2502-0485
(exp. 1/31/2015)

Please read the Instructions and the Public Reporting Statement before completing this form
Name & Address of Grantee
Name & Address of Project (if different)

Note: Grantees with multiple sites must complete a form for each site and submit
aggregate information to HUD.

Reporting Period
Oct. 1, 20___ to
Sept. 30, 20____

Grantee No.

Contact Person

1. Type of Project (check only one box)
Elderly/Disabled Mixed
12345678901234567
For-Profit
Non-Profit
12345678901234567
PHA
IHA
202

12345678901234567
12345678901234567
12345678901234567
12345678901234567
12345678901234567
12345678901234567
12345678901234567
12345678901234567
12345678901234567
12345678901234567
12345678901234567

Phone No.

2a. Range of all participants' ages
Non-Elderly/Disabled
1234567890123456
For-Profit
Non-Profit
1234567890123456

1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456
1234567890123456

Youngest
Oldest
2b. Average age
Elderly
Non-Elderly Disabled

236
3. Average number of weeks temporarily disabled served by
CHSP

221 (d)
Sec. 8

Elderly Disabled

RHS
4. Numbers and Types of People Served
a. Elderly/
Total No. of
Non-Elderly Disabled
Participants

Non-Elderly Disabled

White
(Non-Hisp)

Black
(Non-Hisp)

Race/Ethnicity
American Indian
Asian or
Alaskan Native Pacific Islander

Hispanic

M 62+
F 62+
M 18-61
F 18-61
Subtotal
b. Temporarily Disabled
M 62+
F 62+
M 18-61
F 18-61
Subtotal
c. Grand Total
Previous edition is obsolete

Page 1 of 2

ref. Handbook 4640.1

form HUD-90006 (5/96)

5. Services Provided * Total No.
of Units
Service Type
Provided
a.
b.

Unit
Type
c.

Case Management

hours

Meals

meals

Housekeeping Aid

hours

Personal Assistance

hours

Transportation

Number of
Participants
Served
d.

Cost Distribution.
Enter the dollar amounts expended and the source
Total Cost

Match/Grantee Cont.

Partic. Fees

HUD Grant

e.

f.

g.

h.

one-way trip

Other: (list)

Administration
Total

1234567890123456789012345678901212
1234567890123456789012345678901212
1234567890123456789012345678901212
1234567890123456789012345678901212
1234567890123456789012345678901212
1234567890123456789012345678901212
1234567890123456789012345678901212
1234567890123456789012345678901212
1234567890123456789012345678901212
1234567890123456789012345678901212

12345678901234
12345678901234
12345678901234
12345678901234
12345678901234
12345678901234

* Note: List unit type in column c for "Other" services listed. Numbers in column d must be equal to or less than those in line 4c.
6a. Number of participants who use 6b. Total dollar amount collected
7. Dollar value of surplus commodities received from the
food stamps to pay meals fees
from food stamps
Department of Agriculture
8.

Number of new participants who joined the CHSP during the reporting period and breakdown by source
Total number who
From within CHSP project
From other HUD projects
From nursing homes
joined CHSP

From hospitals

9.

From own private home/apt. From board and care
facilities

Other (specify)

Number of participants who left the CHSP during the reporting period and breakdown by reason
Total number
Death
Permanently relocated
Permanently relocated
who left CHSP
to a nursing home
to a hospital

Out of CHSP but
remained in the project

From mental
institutions

Relocated to family

Other (specify)

10. Attach a brief narrative report describing the operation of the CHSP during the reporting period. Include issues or problems concerning
the operation of the CHSP, e.g. workload of the PAC and the Service Coordinator, provision of services, fee scale, attracting or maintaining
the number of participants planned for the program, etc.
Prepared by (Print name)
Signature
Date

Reviewed by (for Grantee agency)(Print name)

Signature

Date

Reviewed by (GTR's Name & Field Office)

Signature

Date

GTR comments:(Attach a separate page if necessary.)

Previous edition is obsolete

Page 2 of 2

ref. Handbook 4640.1

form HUD-90006 (5/96)

Public reporting burden for this collection of information is estimated to average 14 hours per response, including the time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This agency may not conduct or sponsor, and
a person is not required to respond to, a collection of information unless that collecton displays a valid OMB control number. The information is basic to the operations
of the Congregate Housing Services Program. It supports statutory requirements and program and management controls that prevent fraud, waste and
mismanagement. The controls must be maintained as long as current grants are in operation. Section 802 of the National Affordable Housing Act authorizes/
requires matching funds and participant fee collections that are reported onthese forms. The rule at 24 CFR 700.155(d) requires grantees to submit these forms.
The information will be used by State/Area offices to ensure that grant funds are being used properly. This includes grantees’ expense of appropriate grant
monies during each annual grant period and the use of grant funds to provide eligible activities to eligible residents, and to ensure that statutory requirements
are being met. Program staff use the information to compile annual program data. Grantees must complete forms and report grant activity in order to continue
receiving grant funds. Each grantee is required to maintain confidentiality of information related to any individual, per the Privacy Act of 1974.

Instructions for Completing the Congregate Housing Services Program Annual Reporting Form HUD-90006
2a. Range of Participant Ages
Youngest: Enter the age of the youngest participant
Oldest:
Enter the age of the oldest participant
2b. Average Age
Elderly:
Enter the average age of all participants
aged 62 or older.
Non-elderly disabled: Enter the average age of all
participants aged 18 to 61

The data requested on this form represent numbers of
people served and dollar amounts expended during the
reporting period. Grantees are asked to complete this
form for each Federal fiscal year - October 1 through
September 30. This twelve month period is the reporting
period. Completed annual report forms are due to your
local GTR on October 30 of each year, along with your
fourth quarterly report.
Information provided on this report must reflect the
actual costs spent on services and administration during
the reporting period. The costs reported should cover
only the activities listed in your budgets.
The GTR will send your completed Annual Report to the
HUD Headquarters program office. Staff will use these
reports to evaluate the CHSP and to write an Annual
Report to Congress, that will provide performance data
for the just-ended Federal fiscal year.
Preliminary Information
Make sure you have completed the information at the top
of the form:
o Name and Address of Grantee
o Name and Address of Project, if different
o Years of the reporting period
o Grant Number
o Contact Person (who completed the form)
o Contacts Phone Number

3. Average number of weeks temporarily disabled
served by CHSP:
Temporarily disabled individuals are those who become
disabled for a short-term period. They need the assistance of CHSP services during the time they recuperate
and before they can return to fully independent living.
Examples of such participants may be someone who
breaks his/her hip or becomes very ill for a prolonged
period of time.
Enter the average number of weeks these participants
are provided CHSP services. Enter an average time
period for elderly disabled individuals, aged 62 and
older, and a separate average time period for nonelderly disabled participants, aged 18 to 61.
4. Number & Type of Participants Served
List the total number of people served throughout the
reporting period. To derive the total, either (a) add the
number of participants in the CHSP as of October 1
(beginning of the period) to the number of new participants who joined the program during the reporting
period (item #8), or (b) add the number of participants in
the program as of September 30 (end of the period) to
the number who left the program during the reporting
period (item #9). The total number will be the same either
way. If participants leave and new ones join the CHSP
during the reporting period, the total number listed in line
c “Grand Total” may be greater than the maximum
number of participants allowed by your grant agreement.
This is okay as long as at any one time you do not serve
more than this maximum number. Be sure to count
only those people who are PAC-approved participants of CHSP.
Indicate in the appropriate boxes the number of participants
that fall into the identified gender, age and racial/ethnic
categories. The first five rows refer to Elderly/Non-Elderly
Disabled participants who are permanently impaired. The
last five rows refer to "Temporarily Disabled” persons.

1. Type of Project
Check only one appropriate box. Only check the
Section 8 line if your building was developed with Section 8 new construction or substantial rehabilitation funds.
If the CHSP project is an elderly designated building and
you serve either all elderly or both elderly and nonelderly disabled persons, check the Elderly/Disabled
Mixed column. If your project was developed primarily
for the non-elderly disabled, check the Non-elderly Disabled column. Do not check boxes in both columns;
your project must be one or the other.
2. Age Information - Items 2 & 3
These items refer to all participants served, both those
permanently impaired and temporarily disabled.

Previous edition is obsolete

Page i

ref. Handbook 4640.1

form HUD-90006 (5/96)

5. Services Provided
This part of the form serves as an annual summary of the
types and amounts of services provided, the numbers of
participants served, and the dollar amounts expended.
Program expenses are paid for by moneys that are:
o contributed as match;
o collected from participants as fees, and
o received from your HUD/CHSP grant as reimbursement.
Funds received from these three sources must be used
to cover all the costs incurred for your CHSP program.
In other words: Total Program Costs equals Match
plus Fees plus Grant (or as described below: Column
e = f + g + h).
Part 5 consists of the following information:
a. Service Type
b. Total Number of Units Provided
c. Unit Type
d. Number of Participants Served
e. Total Cost
f.
Match/Grantee Contribution
g. Participant fees
h. HUD Grant Amount
a. Service Type
List information in columns b and d-h for the listed
services. For services you provide that are not listed,
write them in on the other lines and enter the relevant
information in columns b-h. Be sure to include the unit
type in column c .
b. No. of Units Provided During Report Period
c. Unit Type
A "unit" is usually defined as one hour of service, one
meal or a one-way trip. Enter the actual total number of
units provided to all participants throughout the reporting
period.
Enter the total number of hours provided over the reporting period for case management, housekeeping aid,
personal assistance (and any other like service). Report
the total number of meals provided in the meals line.
Enter the total number of one-way trips for transportation. For "other" services you may add, we recommend
listing "hour" as the unit type for services such as mental
health or other types of counseling, escort services, and
preventive/wellness health programs.
We encourage you to maintain your own records of the
services you provide using the unit types listed in column
c of the form, (i.e. hours, meals and one-way trips for the
corresponding services.) This will enable you to complete this form more easily in the future.

Previous edition is obsolete

d. Number of Participants Served
Enter in each line the number of different participants
who received that service at any time during the reporting period. The numbers in this column must be equal to
or less than the total number of participants listed on line 4c.
e. thru h. Program Funds Distribution
As on the CHSP budget sheets, expenditures for each
service and for administration must be broken down and
presented into three categories: match/grantee contribution, participant fees and HUD grant funds. The
Annual Report shows how each funding source is used
to cover costs incurred for each service.
The dollar amounts provided in these columns must
reflect the actual amounts of funds obtained from HUD;
collected from participants, and contributed by the grantee
or other providers over the reporting period. By looking
at this annual report, the reader understands that the
amounts listed in each column for each service were
actually used to pay the indicated portion of the services
cost.
These amounts must not be estimates. They must be
real dollar amounts that can be justified by the grantees
financial statements.
All grantees must be collecting participant fees and
contributing some matching funds and/or resources.
Therefore some amount must be entered in these two
columns. (See your Summary Budget, HUD-91180 or
91180-B for the corresponding columns listed below.)
e. Total Cost
This refers to the total cost of providing each service for
the entire reporting period. The total cost must be the
sum of the Match/Grantee Contribution, Participant Fees,
and HUD Grant columns. (See the Total Cost column
on the HUD-91180/91180-B.) The dollar amount entered in the box joining the Total Cost column and the
Total line must represent the entire cost of the CHSP
program over the reporting period. The next three
columns (f, g, and h) simply explain what resources were
used to pay these costs. (See row VII, Total Cost column
of the HUD-91180/91180-B.)
f. Match/Grantee Contribution
This refers to the combination of any funds or resources
(including in-kind) that are contributed by the grantee or
other providers. These funds and resources must be
used to cover a portion of the cost of providing services.
(See Total Applicant Match column on the HUD-91180/
91180-B.)
g. Participant Fees
These are the dollar amounts collected from program
participants. These fees also must be used to cover a
portion of the cost of providing one or more services.
Include donations to Title III-C programs where applicable. (See Participant Fees column on the HUD91180/91180-B.)

Page ii

ref. Handbook 4640.1

form HUD-90006 (5/96)

h. HUD Grant
This refers to costs covered by funds received from your
CHSP grant from HUD. These amounts constitute your
reimbursements from HUD. (See CHSP Funds Requested column on the HUD-91180/91180-B.)
An example: Using the meals costs stated below, we've
determined that providing meals for the entire twelve
month period costs a total of $30,240. This includes raw
food cost, labor costs for food preparers/servers and the
rental cost of dining room space. The cost distribution
would be as follows:
Total Cost
$30,240
less Applicant Match:
7,010
less Participant Fees:
5,230
HUD Grant:
$18,000
6a. No. of participants who used food stamps to pay
meals fees
Remember that grantees must apply for approval as a
retail food store; accept food stamps as a means of
payment for meals, and request and use agricultural
commodities to prepare such meals. (See CHSP Common Rule at 24 CFR Part 700.210(3)(v) or 7 CFR Part
1944.255(3)(v).)
Enter in box 6a the number of participants who use food
stamps to pay their meals fees.
6b. Total dollar amount collected from food stamps
This is the dollar amount of the food stamps collected
from the participants counted in 6a. This dollar amount
should be part or the whole of the meals fees amounts
collected and listed in #5: Meals line and Participant
Fees column.
7. Dollar value of surplus commodities received
from the Department of Agriculture
If you receive surplus commodities, provide the dollar
value of all the commodities received during the reporting period.

Previous edition is obsolete

8. No. of new participants who joined the CHSP
during the reporting period and breakdown by source:
Provide the total number of new participants that entered the program only during the reporting period.
For example, lets say four new participants entered a
grantees program over the reporting period; two came
from their own homes and one each from a hospital and
a board and care facility. A "4" should be entered in the
Total no. of people who entered CHSP box. A "2" should
be entered in the From own homes/apts box and a "1"
in both the From hospitals and From board and care
facilities boxes. If a participant(s) came from a place not
listed, indicate the number and the place(s) in the Other
box.
Numbers entered in the From within CHSP project box
should refer to people who already lived in the HUD
project where the CHSP is located, but previously were
not participants.
Numbers entered in the From other HUD projects box
refer to people who moved from any other HUD project
in order to participate in the CHSP. Providing project
names is not required.
9. No. of participants who left the CHSP during the
reporting period and breakdown by reason:
Indicate the number of participants who left the CHSP
program only during the reporting period.
For example, lets say four participants also left the
program during the reporting period. Two died, one was
permanently relocated to a nursing home and one went
to live with her family. A "4" would be entered in the Total
no. of participants who left CHSP box. A "2" would be
entered in the Death box and a "1" would be entered in
both the Permanently relocated to a nursing home and
Relocated to family boxes. If a participant(s) leaves the
program and goes to a place not listed, please indicate
the number and place(s) in the Other box.
10. Narrative Report. Attach a brief narrative report
describing the operation of the CHSP during the reporting period. Include issues or problems concerning the
operation of the CHSP, e.g. workload of the PAC and the
Service Coordinator, provision of services, fee scale,
attracting or maintaining the number of participants
planned for the program, etc.

Page iii

ref. Handbook 4640.1

form HUD-90006 (5/96)

Previous edition is obsolete

ref. Handbook 4640.1

form HUD-90006 (5/96)

CHSP Services and Allowable Costs
Note: Costs of providing the following services can include direct hire,
contract costs, and the cost of volunteer time valued at $5.00 per hour.
1. Case Management
Each grantee must provide case management services
to all CHSP participants. The costs of employing a
service coordinator (and Title V senior workers or volunteers) used to provide the following services are part of
the total cost of case management. Administrative costs
directly related to program activities (e.g. a computer or
office supplies used to keep participant files, etc.) are
also part of the total cost.

Examples of personal care services include receiving assistance with:
o grooming
o dressing
o using the toilet (getting to the toilet, cleaning self,
arranging clothing)
o bathing and personal hygiene; hair, skin, and foot
care
o clothes care
o cooking, preparing or serving food
o getting in and out of bed and chairs
o walking
o going outdoors

Case management may include the following:
o initial screening of residents for referral to the
PAC;
o developing and monitoring of case plans in coordination with a formal assessment of needed
services;
o establishing linkages with appropriate agencies
and service providers in the general community in
order to tailor the needed services to the participants;
o linking program participants to providers of services that the participant needs, and
o educating participants on issues, including, but
not limited to, supportive service availability, application procedures and client rights.

5. Transportation Services
Car, taxi, van, or bus service is most often used. Transportation can be provided to medical clinics, social
service agencies, shopping areas, grocery stores, religious institutions, and libraries. Costs may include labor
time, purchase/lease costs, insurance, vehicle maintenance and fuel.
Examples of Other Allowable Services or Activities
Counseling Services:

2. Meal Service

Counseling could include:

Grantees must make available to all CHSP participants
a meal service that is adequate to meet nutritional
needs. This service must include at least one hot meal
a day, seven days a week, served in a group setting.

o social work counseling (such as short-term assistance with personal or family problems);
o legal and financial counseling (including help in
applying for entitlement programs);
o bereavement and other types of mental health
counseling, and/or
o family counseling.

Total costs of meals may include costs of labor, raw food,
the rent of dining room space, and utilities and the
purchasing cost of small kitchen appliances, dishes and
utensils.
Light housekeeping services may include assistance
with making beds, washing, vacuuming, dusting, bathroom cleaning, and laundry. Costs usually include labor
time and needed supplies.

Trained professionals or students-in-training should
perform these services. Counseling here is distinguished from case management performed by the service coordinator in that it would be more intensive and
on-going. Costs of labor and possibly space would be
acceptable.

4. Personal Assistance

Escort Services:

Personal assistance costs normally include the costs of
labor time and needed supplies.

Escort services might assist individuals in moving
around their apartment or some other space, visiting a
doctor or going shopping. Escort services are normally
performed by volunteers or by individuals or project
residents paid a low wage. Costs are usually just labor
costs.

3. Housekeeping Aid

Previous edition is obsolete

Page 1 of 2

ref. Handbook 4640.1

form HUD-90006 (5/96)

CHSP Services and Allowable Costs (Con't.)
Health Related Services:

Adult Day Care:

Such services might include the following:

Costs associated with non-medical components of adult
day care and transportation to and from the day care site
are acceptable.

o supervision of health-related needs (e.g. ensuring
the provision of mobility devices and special diets,
participation in health regimens or exercise;
o wellness programs;
o preventive health screening, and
o monitoring of medication consistent with State
law.

Personal Emergency Response Systems:
These are systems that will allow residents to call for
emergency aid through the use of hand-held units or
devices worn around the neck. The costs of purchasing
and maintaining these systems are allowable.

A variety of professionals and volunteers may be employed to provide these services. Costs may include
labor time, space, utilities, and supplies.

Previous edition is obsolete

Page 2 of 2

ref. Handbook 4640.1

form HUD-90006 (5/96)