APR Revision

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 55 hours per manual response, or less if an automated data collection and retrieval system is in use, along with 60 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.

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. Program Income

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 HOPWA-eligible beneficiaries for a ten (10) year period. 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 5E 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. In the case that HUD must review client level data, no client names or identifying information will be retained or recorded. 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 HOPWA 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(ies): All members of a household who received HOPWA assistance during the operating year including the one individual who qualified the household for HOPWA assistance as well as any other members of the household (with or without HIV) who benefitted from the assistance.

Central Contractor Registration (CCR): The primary registrant database for the U.S. Federal Government. CCR collects, validates, stores, and disseminates data in support of agency acquisition missions, including Federal agency contract and assistance awards. Both current and potential federal government registrants are required to register in CCR in order to be awarded contracts by the federal government. Registrants must update or renew their registration at least once per year to maintain an active status. Although recipients of direct federal contracts and grant awards have been required to be registered with CCR since 2003, this requirement is now being extended to indirect recipients of federal funds with the passage of ARRA. Per ARRA (American Recovery and Reinvestment Act) and FFATA (Federal Funding Accountability and Transparency Act) federal regulations, all sub-grantees or subcontractors receiving federal grant awards or contracts must have a DUNS (Data Universal Numbering System) Number and be registered with the CCR (Central Contractor Registration).

Chronically Homeless Person: An unaccompanied homeless individual (age 18 years or older) with a disabling condition or a family with at least one adult member (age 18 years or older) who has 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 or 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.

Faith-Based Organization: Religious organizations of three types: (1) congregations; (2) national networks, which include national denominations, their social service arms (for example, Catholic Charities, Lutheran Social Services), and networks of related organizations (such as YMCA and YWCA); and (3) freestanding religious organizations, which are incorporated separately from congregations and national networks.

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.”

HOPWA Eligible Individual: The one (1) low-income person with HIV/AIDS who qualifies a household for HOPWA assistance. This person may be considered “Head of Household.” When the APR asks for information on eligible individuals, report on this individual person only. Where there is more than one person with HIV/AIDS in the household, the additional PWH/A(s), would be considered a beneficiary(s).

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 Assistance Total: This total is the unduplicated number of households receiving housing subsidies and residing in units of facilities dedicated to persons living with HIV/AIDS and their families and supported with HOPWA or leveraged funds during the operating year.

Housing Stability: The degree to which the HOPWA project assisted beneficiaries remain in stable housing during the operating year. See Part 6: Worksheet definitions of stable and unstable housing situations.

In-Kind Leveraged Resources: These involve additional types of organizational supports, such as volunteer services, materials, use of building space and equipment, provided to assist HOPWA beneficiaries. 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 Funds: 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.

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.

Project-Based Rental Assistance (PBRA): A rental subsidy program that is tied to specific facilities or units owned or controlled by a project sponsor. Assistance is tied directly to the properties and is not portable or transferable.

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.

Project Sponsor Organizations: Any nonprofit organization or governmental housing agency that receives funds under a contract with the grantee or subrecipient to provide housing and other support services as defined in 24 CFR 574.300.

Short-Term Rent, Mortgage, and Utility (STRMU) Assistance: A time-limited housing assistance designed to prevent homelessness and increase housing stability. Grantees may provide assistance for up to 21 weeks in any 52 week period. The amount of assistance varies per client depending on funds available, tenant need and program guidelines.

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

Subrecipient Organization: Organizations that hold an agreement with the grantee or sponsor agencies to provide administrative or limited implementation activities that do not involve direct services to clients. Examples of these organizations are as follows; evaluation firms, construction firms, administrative agencies, etc. Agreements include: grants, subgrants, loans, awards, cooperative agreements, and other forms of financial assistance; and contracts, subcontracts, purchase orders, task orders, and delivery orders

Tenant-Based Rental Assistance (TBRA): TBRA is a rental subsidy program similar to Section 8 that grantees can provide to help low-income households access affordable housing.  The TBRA voucher is not tied to a specific unit, so tenants may move to a different unit without losing their assistance, subject to individual program rules. The subsidy amount is determined in part based on household income and rental costs associated with the tenant’s lease.

Total by Type of Housing Assistance Type/Services: : The unduplicated households assisted 1) in units by type of housing assistance dedicated to persons living with HIV/AIDS and their families, or 2) services provided that were supported with HOPWA and leveraged funds during the operating year.

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)

Please use charts 1 and 2 in this section to provide more detailed information about the agencies and organizations responsible for the administration and implementation of the HOPWA program. Chart 1 requests general Grantee Information and Chart 2 requests Subrecipient Information. Complete only the tables applicable to the HOPWA project detailed in the report. When completing the tables, provide a response for every question using “N/A” to indicate if a particular question is not applicable to the Grantee or Subrecipient.

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)	     		Central Contractor Registration (CCR): Is the grantee’s CCR status currently active? Yes No If yes, provide CCR Number:
Congressional District of Grantee’s Business Address	     
*Congressional District(s) of Primary Service Area	                             
*Zip Code(s) of Primary Service Area	                             
*City(ies) and County(ies) of Primary Service Area	Cities:                              						Counties:                        
Organization’s Website Address      		Does your organization maintain a waiting list? Yes No If yes, explain in the narrative section how this list is administered.
Is the grantee a nonprofit organization? Yes No Please check if yes and a faith-based organization? Please check if yes and a grassroots organization?

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

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)      

2. Subrecipient Information/Grantee Activities

Provide information on each Subrecipient 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 5A: Summary of Project Sponsor Information. Additionally, if the grantee undertakes service delivery activities directly, complete the respective performance sections (Part 5A-5E) for all activities conducted by the grantee

Note: If any information is not applicable to your organization, please report N/A in the appropriate box.

Note: Please see the definitions for project sponsor and subrecipient for distinction.

Organization      			Parent Company (if applicable)      
Name and Title of Contact at Sub-recipient 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)/	     			Central Contractor Registration (CCR): Is the grantee’s CCR status currently active? Yes No
North American Industry Classification System (NAICS) Code	     
Congressional District of Sub-recipient’s Business Address	     
Congressional District(s) of Primary Service Area	     
Zip Code(s) of Primary Service Area	                             
City(ies) and County(ies) of Primary Service Area	Cities:                             				Counties:                       
Total HOPWA Subcontract Amount of this Organization for the operating year	     
	End of Part 1

Part 2: Grantee Narrative and Performance Assessment

Use the Grantee Narrative and Performance Assessment (items A through D) to succinctly describe in a one to three page narrative how activities enabled client households to improve housing stability, increased access to care and support, and reduced their risk of homelessness. Describe the organization of the HOPWA Program and how the program interacts with other housing and supportive service programs in the community and/or state. The narrative should detail program accomplishments, barriers to achieving state performance goals, technical assistance needs and innovative outreach and support strategies utilized by project sponsors or partner organizations to achieve program goals. 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 program did not achieve expected targets, 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. If your program exceeded program targets, please describe strategies the program utilized and how those contributed to program successes.

     

C. Barriers and Recommendations. Describe any barriers (including regulatory and non-regulatory) encountered in the administration or implementation of the HOPWA program, 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 Discrimination/Confidentiality Supportive Services Housing Affordability	Planning Multiple Diagnoses Credit History	Housing Availability Eligibility Rental History	Rent Determination and Fair Market Rents Technical Assistance or Training Criminal Justice History
	Geography/Rural Access Other, please explain further      

     

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

     

E. 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 any HOPWA-funded housing assistance in this service area. If data is collected on the type of housing that is needed, in rows a through c enter the total number of HOPWA-eligible households by type of housing assistance needed. Do not include clients who are already receiving HOPWA-funded housing 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:

a. 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. Planning Estimate 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) Of those households with an STRMU unmet need, how many need: Assistance with rental costs Assistance with mortgage payments Assistance with utility costs	                       
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

End of Part 2

Part 3: Summary Overview of Grant Activities

A. Information on Individuals, Beneficiaries, and Households Receiving HOPWA Housing Assistance (TBRA, STRMU, Facility-Based Units and Master Leased Units Only. Do not count Supportive Services in this section)

Section 1. Individuals

In Chart a, provide the total number of eligible (and unduplicated) low income individuals living with HIV/AIDS who qualified their household to receive HOPWA housing assistance during the operating year. This total should include only the individual who qualified the household for HOPWA assistance but NOT all HIV positive individuals in the household. In Chart b, report the prior living situations for all individuals reported in Chart a. In Chart c, indicate the number of eligible individuals reported in chart b., Line 5 as homeless who also are homeless Veterans and/or meet the definition for Chronically Homeless (See Definition section of APR). The totals in Chart c. do not need to equal the total in chart b., Line 5.

a. Total HOPWA eligible individuals* living with HIV/AIDS

Individuals Served with Housing Assistance	Total Number
Number of individuals with HIV/AIDS who qualified their household to receive HOPWA housing assistance	 

*See definition section for clarification on HOPWA eligible individuals

b. Prior Living Situation.

Indicate the prior living arrangements for all the individuals reported in Chart a. In row 1, report the total number of individuals who continued to receive HOPWA housing assistance from the prior operating year into this operating year. In rows 2 through 16, indicate the prior living arrangements for all new HOPWA housing assistance recipients during the operating year.

Data Check: The total number of eligible individuals served in Row 18 should equal the total number of individuals served through HOPWA 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 or by agency/organization funds)	 
4.	Transitional housing for homeless persons	 
5.	Total number new individuals who received Housing Assistance with a Prior Living Situation that meets HUD definition of homelessness (Sum of Lines 2 – 4)
6.	Permanent housing for formerly homeless persons (such as Shelter Plus Care, SHP, or SRO Mod Rehab)	 
7.	Psychiatric hospital or other psychiatric facility	 
8.	Substance abuse treatment facility or detox center	 
9.	Hospital (non-psychiatric facility)	 
10.	Foster care home or foster care group home	 
11.	Jail, prison or juvenile detention facility	 
12.	Rented room, apartment, or house	 
13.	House you own	 
14.	Staying or living in someone else’s (family and friends) room, apartment, or house	 
15..	Hotel or motel paid for by individual	 
16.	Other	 
17.	Don’t Know or Refused	 
18.	TOTAL of New Households(Line 18 should equal the sum of Lines 2-17)	 

c. Homeless Individuals Summary. Note: Of those New individuals who received HOPWA Housing Assistance support during Operating Year identified with a prior living situation of homelessness in chart b, line 5 above, how many can be identified as a veteran or chronically homeless. The totals in chart c do not have to equal line 5 in chart b. above (subset of Chart b., Line 5 above). See Definition section for clarification on Chronically Homeless.

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

Section 2. Beneficiaries

In Chart a, report the total number of HOPWA eligible individuals living with HIV/AIDS (as reported in Part 3A, Section 1, Chart a), and all associated members of their household who benefitted from receiving HOPWA housing assistance (resided with HOPWA eligible individuals. In Charts b and c, indicate the age, gender, race and ethnicity for all beneficiaries reported in Chart a.

Note: See definition of “HOPWA Eligible Person”.

Note: Transgender is identified as identification with, or presentation as, a gender that is different from the gender at birth.

Note: The sum of each of the charts b& c should equal the total number of beneficiaries served with HOPWA housing assistance, in Chart a, Row 3.

a. Total Number of Beneficiaries Served with HOPWA Housing Assistance

Individuals and Families Served with Housing Assistance	Total Number
1. Number of individuals with HIV/AIDS who received HOPWA housing assistance (should equal Part 3A,Section 1,Chart a )	 
2. Number of ALL other persons (with or without HIV) residing with the above eligible individuals in HOPWA-assisted housing	 
3. TOTAL number of beneficiaries served with Housing Assistance (Line 3 should be the sum of Lines 1 & 2)	 

b. Age and Gender

Category		Male		Female		Transgender M to F		Transgender F to M
		HOPWA Eligible Individuals	Other Beneficiaries	HOPWA Eligible Individuals	Other Beneficiaries	HOPWA Eligible Individuals	Other Beneficiaries	HOPWA Eligible Individuals	Other Beneficiaries
1.	Under 18	 	 	 	 
2.	18 to 30 years	 	 	 	 
3.	31 to 50 years	 	 	 	 
4.	51 years and Older	 	 	 	 
Total Number of Beneficiaries Served: _______________________________________ (Should equal the total number of beneficiaries as reported in Chart a, line 3.)  

c. Race and Ethnicity*

Category		HOPWA Eligible Individual		Other Beneficiaries		Category		HOPWA Eligible Individual		Other Beneficiaries
		[A]	[B]Also identified as Hispanic or Latino	[A]	[B]Also identified as Hispanic or Latino			[A]	[B]Also identified as Hispanic or Latino	[A]	[B]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	 	 	 	 
Total Beneficiaries from Column [A] Lines 1 through 10 (include both HOPWA Eligible Individuals and Other Beneficiaries): ____________ Total must equal the total in Section 2, Chart a.Line 3 Total Hispanic or Latino Beneficiaries served with HOPWA Housing Assistance from Column [B] Lines 1 through 10: __________________ Total is a subset of Column [A]

*Reference (data requested consistent with Form HUD-27061 Race 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.

Data Check: The total number of households served with housing assistance should equal Part 3C, Row 6 and Part 3A, Section 1, Chart a (Total Individuals Served with HOPWA Housing Assistance).

Note: Refer to http://www.huduser.org/portal/datasets/il/il2010/select_Geography_mfi.odn 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)	 
5.	Total (Total should be the sum of Lines 1-4)	 

Part 3: Summary Overview of Grant Activities

B. Program Income

In Chart 1, indicate the total amount of program income directly generated from the use of HOPWA funds, including repayments. In Chart 2 indicate on what HOPWA activities the project expended the program income gathered during the operating year (total amount reported in chart 1).

Note: Please see report directions section for definition of program income. (Additional information in HOPWA oversight guide on tracking and use of program income)

1. Total Amount Program Income Collected During the Operating Year by Activity Type

[1] Program Income Collected		Total Amount of Program Income (for this operating year)
		[2] Housing Assistance	[3] Supportive Services and other non-direct housing costs
1.	Program income (does not include payments from tenants to landlords)	     	     
2.	Resident rent payments in Rental, Facilities, and Leased Units	     	     

2. Total Amount of Program Income Expended To Assist HOPWA Households

[1] Program Income Expended		Total Amount of Program Income (for this operating year) Used to Assist HOPWA Households
		[2] Housing Assistance	[3] Supportive Services and other non-direct housing costs
1.	Program income (does not include payments from tenants to landlords)	     	     
2.	Resident rent payments in Rental, Facilities, and Leased Units	     	     

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 each program activity provided. In each activity section, the total line must contain an unduplicated total number of households assisted. An adjustment for duplication line is provided in each section to ensure that the total is correct.

Note: Data in this section is summarized from all project sponsors PART 5A-E 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: Number of Households	[2] Amount of HOPWA Funds Expended
1.	Tenant-Based Rental Assistance		     	     
2a.	Permanent Housing Facilities: Received Operating Subsidies/Leased units		     	     
2b.	Transitional/Short-term Facilities: Received Operating Subsidies		     	     
3a.	Permanent Housing Facilities: Capital Development Projects placed in service during the operating year		     	     
3b.	Transitional/Short-term Facilities: Capital Development Projects placed in service during the operating year		     	     
4.	Short-term Rent, Mortgage, and Utility Assistance		     	     
5.	Adjustment for duplication (subtract)		     
6.	TOTAL Housing Assistance (Line 6 is sum of Lines 1-5)		     	     
Housing Development (Construction and Stewardship of Facility-Based Housing)			[1] HOPWA Assistance Outputs: Number of Housing Units	[2] Amount of HOPWA Funds Expended
7.	Facility-Based Units; Capital Development Projects not yet opened		     	     
8.	Stewardship units subject to 3- or 10- year use periods		     
9.	TOTAL Housing Development (Line 9 is sum of Lines 7 and 8)		     	     
Supportive Services			[1] HOPWA Assistance Outputs: Number of Households	[2] Amount of HOPWA Funds Expended
10a		Supportive Services provided by project sponsors that also delivered HOPWA housing assistance (as reported in Part 5D, 1a)	     	     
10b.		Supportive Services provided by project sponsors that only provided supportive services (as reported in Part 5, D, 1b)	     	     
11.		Adjustment for duplication (subtract)	     
12.		TOTAL Supportive Services	     	     
Housing Placement Assistance Activities			[1] HOPWA Assistance Outputs: Number of 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 (Total should equal the sum of Lines 13-15)		     	     
Grant Administration and Other Activities			[1] HOPWA Assistance Outputs: Number of 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 should equal the sum of Lines 17-22)		     	     
TOTAL Expended				[2] Amount of HOPWA Funds Expended
24.	TOTAL Expenditures (Sum of Rows 6, 9, 12, 16 & 23)			     

End of Part 3

Part 4: Summary of Performance Outcomes

Housing Stability, Prevention of Homelessness, and Access to Care

In Column 1, report the total number of households that received HOPWA housing assistance, by type.

In Column 2, enter the number of households continuing to access each type of housing assistance into the following year.

In Column 3, report the housing status of all households that exited the program.

Data Check: 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).

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

1. Permanent Housing Assistance

	[1] Total Number of Households that Received HOPWA Housing Assistance	[2] Assessment: Number of Households that Continued Receiving Housing Assistance into the Next Operating Year	[3] Assessment: Number of Households that exited this HOPWA Program; their Housing Status after Exiting		[4] HOPWA Client Outcomes
Tenant-based Rental Assistance	     	     	1 Emergency Shelter/Streets	     	Unstable Arrangements
			2 Temporary Housing	     	Temporarily Stable, with Reduced Risk of Homelessness
			3 Private Housing	     	Stable/Permanent Housing (PH)
			4 Other HOPWA	     
			5 Other Subsidy	     
			6 Institution	     
			7 Jail/Prison	     	Unstable Arrangements
			8 Disconnected/Unknown	     
			9 Death	     	Life Event
Permanent Supportive Housing Facilities /Units	     	     	1 Emergency Shelter/Streets	     	Unstable Arrangements
			2 Temporary Housing	     	Temporarily Stable, with Reduced Risk of Homelessness
			3 Private Housing	     	Stable/Permanent Housing (PH)
			4 Other HOPWA	     
			5 Other Subsidy	     
			6 Institution	     
			7 Jail/Prison	     	Unstable Arrangements
			8 Disconnected/Unknown	     
			9 Death	     	Life Event

B. Transitional Housing Assistance

	[1] Total Number of Households Receiving Housing Assistance	[2] Assessment: Number of Households that Continued Receiving Housing Assistance into the Next Operating Year		[3] Assessment: Number of Households that exited this HOPWA Program; their Housing Status after Exiting		[4] HOPWA Client Outcomes
Transitional /Short-term Support Facilities /Units	     	Total number of households that will continue in residences:	     	1 Emergency Shelter/Streets	     	Unstable Arrangements
				2 Temporary Housing	     	Temporarily Stable, with Reduced Risk of Homelessness
				3 Private Housing	     	Stable/Permanent Housing (PH)
				4 Other HOPWA	     
				5 Other Subsidy	     
				6 Institution	     
				7 Jail/Prison	     	Unstable Arrangements
				8 Disconnected/unknown	     
				9 Death	     	Life Event
B1:Total number of households whose tenure exceeded 24 months				     

Section 2. Prevention of Homelessness: Assessment of Client Outcomes on reduced risks of homelessness (Short-Term Rent, Mortgage, and Utility Assistance)

Report the total number of households that received STRMU assistance in Column 1.

In Column 2, identify the outcomes of the households reported in column 1 either at the time that they were known to have left the STRMU program or through the project sponsor’s best assessment for stability at the end of the operating year.

Column 3 provides a description of housing outcomes; therefore, data is not required.

At the bottom of the chart:

• In Row 1a, report those households that received STRMU assistance during the operating year of this report, and the prior operating year.

• In Row 1b, report those households that received STRMU assistance during the operating year of this report, and the two prior operating years.

Data Check: The sum of Column 2 should equal the number of households reported in Column 1.

Assessment of Households that received STRMU 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 (e.g. client switched housing units and is now stable, not likely to seek additional support)	     
	Other HOPWA Housing Assistance (PH)	     
	Other Housing Subsidy (PH)	     
	Institution (e.g. residential and long-term care)	     
	Likely that additional STRMU is needed to maintain current housing arrangements	     	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 operating year of this report that also received STRMU assistance in the prior operating year. (e.g. households that received STRMU assistance in two consecutive operating years)				     
1b. Total number of those households that received STRMU Assistance in the operating year of this report that also received STRMU assistance in the two prior operating years (e.g. households that received STRMU assistance in three consecutive operating years)				     

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

Column [1]: For those households receiving both HOPWA-housing and supportive services, identify the number of households receiving any type of HOPWA housing assistance (TBRA, STRMU, Facility-Based, and Master Leasing) and/or support services from the project sponsor that demonstrated access or maintained connections to care and support within the program year.

Column [2]: Of the client households assisted by project sponsors providing only HOPWA-funded supportive services as reported in Part 3C, Chart 1, Line 10b, report the number of households receiving only supportive services that demonstrated improved access or maintained connections to care and support within the program year.

Note: For information on types and sources of income and medical insurance/assistance, refer to Charts 1C and 1D.

Categories of Services Accessed	[1] Number of Households Receiving Housing Assistance and Supportive Services within the Operating Year	[2] Number of Households Receiving Only Supportive Services within the Operating Year	Outcome Indicator
1. Has a housing plan for maintaining or establishing stable on-going housing	     	     	Support for Stable Housing
2. Had 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. Accessed and maintained medical insurance/assistance.	     	     	Access to Health Care
5. Successfully accessed or maintained qualification for sources of income.	     	     	Sources of Income

Chart 1A, Line4: 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

Chart 1A, Line 5: 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 Worker’s Compensation

General Assistance (GA), or use local program name Private Disability Insurance Temporary Assistance for Needy Families (TANF) Other Income Sources

1B. Households that Obtained Employment

Column [1]: Of the client households assisted by project sponsors providing both HOPWA-housing assistance and supportive services as reported in Part 3C, Chart 1, Line 10a, report on the number of 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.

Column [2]: Of the client households assisted by project sponsors providing only HOPWA-funded supportive services and no HOPWA housing as reported in Part 3C, Chart 1, Line 10a, report on the number of 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	[1] Number of Households that Received Housing Assistance	[2] Number of Households that Received Only Supportive Services
Total number of households that obtained an income-producing job	     	     

End of Part 4

Part 5A: Summary of Project Sponsor Information

For each sponsor, please complete the entirety of Parts 5A-E. Order the report as Part 5A-E for Sponsor 1, then Part 5A-E for Sponsor 2, etc. In Chart 1, provide the following information for organizations designated or selected to serve as a project sponsors, as defined by CFR 574.3. Use this section to report on organizations involved in the direct delivery of services for client households. 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 5A-line 1-5E) for all activities conducted by the grantee.

Note: Subrecipient data is reported in Chart 2 (see definitions for more information regarding the distinction between a sub-recipient and a project sponsor.

Note: If any information is not applicable to your organization, please report N/A in the appropriate box.

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)	     		Central Contractor Registration (CCR): Is the grantee’s CCR status currently active? Yes No If yes, provide CCR Number:
Congressional District of Sponsor’s Business Address	     
Congressional District(s) of Primary Service Area	     
Zip Code(s) of Primary Service Area	     
City(ies) and County(ies) of Primary Service Area	Cities		Counties
Total HOPWA contract amount for this Organization for the operating year	     
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. Sub-recipient 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, sub-grants, loans, awards, cooperative agreements, and other foams of financial assistance; and contracts, subcontracts, purchase orders, task orders, and delivery orders.

Note: Please see the definition of a subrecipient for more information.

Note: If any information is not applicable to your organization, please report N/A in the appropriate box.

Sub-recipient 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 Number (DUNs)	     		Central Contractor Registration (CCR): Is the grantee’s CCR status currently active? Yes No If yes, provide CCR Number:
North American Industry Classification System (NAICS) Code	     
Congressional District of the Sub-recipient’s Business Address	     
Congressional District(s) of Primary Service Area	     
Zip Code(s) of Primary Service Area	                             
City(ies) and County(ies) of Primary Service Area	Cities:                              		Counties:                        
Total HOPWA Subcontract Amount of this Organization for the operating year	     

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 5A line 1-5E) 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 should equal the sum of Lines a and 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 Line b, enter the total number of STRMU assisted households that received assistance with mortgage costs only (no utility costs) and the amount expended by this project sponsor assisting these households. In addition, in Line c, enter the total number of STRMU assisted households that received assistance with both mortgage and utility costs and the amount expended by this project sponsor assisting these households. In Line d, enter the total number of STRMU assisted households that received assistance with rental only (no utility costs) and the amount expended by this project sponsor assisting these households. In Line e, enter the total number of STRMU assisted households that received assistance with both rental and utility costs and the amount expended by this project sponsor assisting these households. In Line f, enter the total number of STRMU assisted households that received assistance with utility costs only (not including rent or mortgage costs) and the amount expended by this project sponsor assisting these households. The total number of households reported in Column 1, Lines b, c, d, e, and f should equal the total number of STRMU households reported in Column 1, Line a. The total amount reported as expended in Column 2, Lines b, c, d, e, and f should equal the total amount of STRMU expenditures reported in Column 2, Line a. The total number of households reported in Column 1, Lines b, c, d, e, and f should equal the total number of STRMU households reported in Column 1, Line a.

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 (STRMU) assistance	   	   
b.	Of the total STRMU reported on Line a, total who received assistance with mortgage costs ONLY.	   	   
c.	Of the total STRMU reported on Line a, total who received assistance with mortgage and utility costs.
d.	Of the total STRMU reported on Line a, total who received assistance with rental costs ONLY.
e.	Of the total STRMU reported on Line a, total who received assistance with rental and utility costs.
f.	Of the total STRMU reported on Line a, total who received assistance with utility costs ONLY.

Part 5: Summary of Project Sponsor Information

C. Facility-based Housing Assistance

Complete one Part 5C for each facility developed or supported through HOPWA funds. Complete Charts 1a, Project Site Information, and 1b, Type of Capital Development Project Units, for all Development Projects, including facilities that are past development projects and continue to receive HOPWA operating dollars.

Charts 2a, 2b and 3 are required for each facility. In Charts 2a, and 2b, indicate the type of facility and number of units in it. In Chart 3, enter the total number of households served and the amount of funds expended to support households in the facility.

If a 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), but HOPWA funds are no longer used to support the facility, the project sponsor should complete the “HOPWA Housing Project Certification of Continued Usage Form” (Part 5E of the report).

1a. Project Site Information for Capital Development of Projects Only (For Current or Past Capital Development Projects that receive HOPWA Operating Costs)

Type(s) of Development		HOPWA Funds Expended (if applicable)	Non-HOPWA funds Expended (if applicable)	Type of Facility [Check only one box.]
New construction		$      	$     	Permanent housing Short-term Shelter or Transitional housing Supportive services only facility
Rehabilitation		$     	$     
Acquisition		$     	$     
Operating		$     	$     
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. Number and Type of Capital Development Project

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

	Number Designated for the Chronically Homeless	Number Designated to Assist the Homeless	Number of Energy-Star Compliant	Number 504 Accessible	Number 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. Number of 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 (SRO) dwelling	   
b.	Community Residence	   	   	   	   	   	   
c.	Project-based Rental Assistance Units or Leased Units (including Master-leased Units)	   	   	   	   	   	   
d.	Other housing facility. Specify:    	   	   	   	   	   	   

3. Households and 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 and Other Activities

In this section, report on the use of HOPWA funds for supportive services. In Table 1, if the project sponsor provides HOPWA funded housing assistance, check 1a. If the project sponsor only provides HOPWA-funded supportive services to client households, check 1b. In Table 2, provide the (unduplicated) total of all households and expenditures for each type of HOPWA-funded supportive service, housing placement, grant administration and other activities provided by the 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 provided by project sponsors delivering only Supportive Services

2. Listing of Supportive Services paid for with HOPWA funds 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	Sub-Total Households receiving Supportive Services (Sub-total should equal the sum of Lines 1-14)	   
16.	Adjustment for Duplication (subtract)	   
17.	TOTAL Households receiving Supportive Services (unduplicated) (Total should be Line 15 minus Line 16)	   	   
Housing Placement Assistance Categories		Number of Households Receiving HOPWA Assistance	Amount of HOPWA funds Expended
18.	Housing Information Services	   	   
19.	Permanent Housing Placement Services	   	   
20	TOTAL Housing Placement Assistance (unduplicated) (Total should equal the sum of Lines 18-19)	   	   
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 (Total should be the sum of Lines 17 + 20 +26)		     

Part 5: Summary of Project Sponsor Information

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

Grantees that used 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 if the facility was acquired, rehabilitated or constructed/developed in part with HOPWA funds, but no additional HOPWA funds were expended in this operating year.

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

Stewardship Units	Number of Units Developed with HOPWA funds	Amount of Leveraging Used during the Operating Year
Total Stewardship Units in Facility (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)	     
Site Information: 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 not confidential: 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 of the organization that continues to operate the facility:      	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)      

End of Part 5

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. Completion of this worksheet is optional.

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.

End of Part 6

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