HUD-40110-C HOPWA Annual Progress Report (APR) Measuring Performance

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 APR report for HOPWA competitively selected grantees provides annual information on program accomplishments that supports program evaluation and the ability to measure program beneficiary outcomes related to: maintain housing stability; prevent homelessness; and improve access to care and support. Reporting is required for all HOPWA competitive grantees. 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. HUD’s requirements for reports submitted by HOPWA formula grantees are supported by 42 U.S.C. § 12911 and HUD’s regulations at 24 CFR § 574.520(b). 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. While confidentiality is not assured, HUD generally only releases this information as required or permitted by law.

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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 must 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 Receiving HOPWA Housing Subsidy Assistance

B. Sources of Leveraging and Program Income

C. Performance and Expenditure Information

PART 4. Summary of Performance Outcomes: Housing Stability, Prevention of Homelessness, and Access to Care

PART 5. Summary of Each Project Sponsor Information

A. Project Sponsor Information

B. Rental Assistance, Short-Term Rent, Mortgage, and Utility Assistance and Permanent Housing Placement Assistance

C. Facility-based Housing Assistance

D. Supportive Services and Other Activities

E. Annual Report of Continued Use for HOPWA Facility-Based Stewardship Units

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 Report of Continued Project Operation throughout the required use periods. This report is included in Part 5E Annual Report of Continued Use for HOPWA Facility-Based Stewardship 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, Disabling Conditions, Residence Prior to Program Entry, Zip Code of Last Permanent Address, Housing Status, Program Entry Date, Program Exit Date, Personal 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, Services Provided, Housing Status or Destination at the end of the operating year, Physical Disability, Developmental Disability, Chronic Health Condition, Mental Health, Substance Abuse, Domestic Violence, Medical Assistance, and T-cell Count. Other HOPWA projects sponsors may also benefit from collecting these data elements. HMIS local data systems must maintain client confidentiality by using a closed system in which medical information and HIV status are only shared with providers that have a direct involvement in the client’s case management, treatment and care, in line with the signed release of information from the client.

Operating Year. HOPWA competitive grants are awarded for a three-year period of performance with APRs submitted for each of the three operating years. The information contained in this APR should reflect the grantee’s operating year with the beginning date determined at the time the grant agreement is signed. Project sponsor accomplishment information must coincide with the operating year this APR covers. Any change to the period of performance requires the approval of HUD by amendment, such as an extension for one additional operating year. A renewal grant start date would be coordinated with the close out of the existing grant.

Grantees with an approved extension period of less than 6-months must submit the APR for the third year of the grant term at the end of the approved extension period and incorporate data from the additional months. Grantees with an approved extension period of 6-months or more must turn in an APR at the end of the operating year and submit a separate extension APR at the end of the extension period.

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

Filing Requirements. Within 90 days of the completion of each operating year, grantees must submit their completed APR to the CPD Director in the grantee’s State or Local HUD Field Office, and to the HOPWA Program Office: at [email protected]. Electronic submission to HOPWA Program office is preferred; however, if electronic submission is not possible, hard copies can be mailed to: Office of HIV/AIDS Housing, Room 7248, U.S. Department of Housing and Urban Development, 451 Seventh Street, SW, Washington, D.C., 20410.

Definitions

Adjustment for Duplication: Enables the calculation of 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 such as HOPWA Subsidy Assistance or Supportive Services. For example, if a client household received both TBRA and STRMU during the operating year, report that household in the category of HOPWA Housing Subsidy Assistance in Part 3C, Chart 1, Column [1] in the following manner:

HOPWA Housing Subsidy Assistance		[1] Outputs: Number of Households
1.	Tenant-Based Rental Assistance	1
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	1
5.	Adjustment for duplication (subtract)	1
6.	TOTAL Housing Subsidy Assistance (Sum of Rows 1-4 minus Row 5)	1

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.

Chronically Homeless Person: An individual or family who : (i) is homeless and lives or resides individual or family who: (i) Is homeless and lives or resides in a place not meant for human habitation, a safe haven, or in an emergency shelter; (ii) has been homeless and living or residing in a place not meant for human habitation, a safe haven, or in an emergency shelter continuously for at least 1 year or on at least 4 separate occasions in the last 3 years; and (iii) has an adult head of household (or a minor head of household if no adult is present in the household) with a diagnosable substance use disorder, serious mental illness, developmental disability (as defined in section 102 of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (42 U.S.C. 15002)), post-traumatic stress disorder, cognitive impairments resulting from a brain injury, or chronic physical illness or disability, including the co-occurrence of 2 or more of those conditions. Additionally, the statutory definition includes as chronically homeless a person who currently lives or resides in an institutional care facility, including a jail, substance abuse or mental health treatment facility, hospital or other similar facility, and has resided there for fewer than 90 days if such person met the other criteria for homeless prior to entering that facility. (See 42 U.S.C. 11360(2)) This does not include doubled-up or overcrowding situations.to which the HOPWA project assisted beneficiaries to remain in stable housing during the operating year. See Worksheet - Determining HOPWA Outcomes and Connections with HMIS for definitions of stable and unstable housing situations.

In-kind Leveraged Resources: These are additional types of support provided to assist HOPWA beneficiaries such as volunteer services, materials, use of equipment and building space. The actual value of the support can be the contribution of professional services, based on customary rates for this specialized support, or actual costs contributed from other leveraged resources. In determining a rate for the contribution of volunteer time and services, use the criteria described in 2 CFR 200. The value of any donated material, equipment, building, or lease should be based on the fair market value at time of donation. Related documentation can be from recent bills of sales, advertised prices, appraisals, or other information for comparable property similarly situated.

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

Live-In Aide: A person who resides with the HOPWA Eligible Individual and who meets the following criteria: (1) is essential to the care and well-being of the person; (2) is not obligated for the support of the person; and (3) would not be living in the unit except to provide the necessary supportive or services. See Code of Federal Regulations Title 24 Part 5.403 and the HOPWA Grantee Oversight Resource Guide for additional reference.

Master Leasing: Applies to a nonprofit or public agency that leases units of housing (scattered-sites or entire buildings) from a landlord, and subleases the units to homeless or low-income tenants. By assuming the tenancy burden, the agency facilitates housing of clients who may not be able to maintain a lease on their own due to poor credit, evictions, or lack of sufficient income.

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 degree to which the HOPWA assisted household has 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 assistance during the operating year.

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

Program Income: Gross income directly generated from the use of HOPWA funds, including repayments. See grant administration requirements on program income at 2 CFR 200.307.

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.

Project Sponsor Organizations: Per HOPWA regulations at 24 CFR 574.3, any nonprofit organization or governmental housing agency that receives funds under a contract with the grantee to provide eligible housing and other support services or administrative services as defined in 24 CFR 574.300. Project Sponsor organizations are required to provide performance data on households served and funds expended.

SAM: All organizations applying for a Federal award must have a valid registration active at sam.gov. SAM (System for Award Management) registration includes maintaining current information and providing a valid DUNS number.

Short-Term Rent, Mortgage, and Utility (STRMU) Assistance: A time limited housing subsidy 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 from HOPWA. Report information is required for facilities that are subject to the minimum use requirements (three-year use agreement if rehabilitation is non-substantial and ten-year use agreement if rehabilitation is substantial).

Tenant-Based Rental Assistance (TBRA): TBRA is a rental subsidy program similar to the Housing Choice Voucher Program 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.

Transgender: Transgender is defined as a person who identifies with, or presents as, a gender that is different from the person’s gender assigned at birth.

Veteran: A veteran is someone who has served on active duty in the Armed Forces of the United States.  This does not include inactive military reserves or the National Guard unless the person was called up to active duty.

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)

This section requests general grantee information. Please use Chart 1to provide more detailed information about the agency(ies) and/or organization(s) responsible for the administration and implementation of this HOPWA program.When completing the chart(s), provide a response for every question using “N/A” to indicate if a particular question is not applicable to the Grantee. Do not leave any sections blank.

Note: Report all general information pertaining to project sponsors that perform housing and supportive services 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; ☐ Ext Yr
Grantee Name      				Parent Company if applicable      
Business Address	     
City, State, Zip, County	     				     	     		     
Employer Identification Number (EIN) or Tax Identification Number (TIN)	     
DUN & Bradstreet Number (DUNs)	     		System for Award Management (SAM): : Is the grantee’s SAM status currently active? ☐ Yes ☐ No If yes, provide SAM Number:
Congressional District of Grantee’s Business Address	     
*Congressional District(s) of Primary Service Area	                             
*City(ies) and County(ies) of Primary Service Area	Cities:                              						Counties:                        
Organization’s Website Address      		Is there a waiting list(s) for HOPWA Housing Subsidy Assistance Services in the Grantee Service Area? ☐ Yes ☐ No If yes, explain in the narrative section what services maintain a waiting list and 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)      

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 stated 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 the different types of housing assistance are 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.

     

End of Part 2

Part 3: Summary Overview of Grant Activities

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

Note: Reporting for this section should include ONLY those individuals, beneficiaries, or households that received and/or resided in a household that received HOPWA Housing Subsidy Assistance as reported in Part 3C, Chart 1, Row 7 (e.g., do not include households that received HOPWA supportive services ONLY).

Section 1. Individuals

a. Total HOPWA eligible individuals* receiving HOPWA Housing Subsidy Assistance

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 subsidy assistance during the operating year. This total should include only the individual who qualified the household for HOPWA housing subsidy assistance but NOT all HIV positive individuals in the household.

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

*See definition section for clarification on HOPWA eligible individuals

b. Prior Living Situation

In chart b, 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 subsidy assistance from the prior operating year into this operating year. In Rows 2 through 17, indicate the prior living arrangements for all new HOPWA housing subsidy assistance recipients during the operating year.

Data Check: The total number of eligible individuals served in Row 18 equals the total number of individuals served through HOPWA housing subsidy assistance reported in Chart a above.

Category		Total HOPWA Eligible Individuals Receiving HOPWA Housing Subsidy Assistance
1.	Continuing to receive HOPWA housing subsidy assistance from the prior operating year	 
New Individuals who received HOPWA Housing Subsidy Assistance support during Operating Year
2.	Place not meant for human habitation (such as a vehicle, abandoned building, bus/train/subway station/airport, or outside)	 
3.	Emergency shelter (including hotel, motel, or campground paid for with emergency shelter voucher)	 
4.	Transitional housing for homeless persons	 
5.	Total number new individuals who received HOPWA Housing Subsidy Assistance with a Prior Living Situation that meets HUD definition of homelessness (Sum of Rows 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 HOPWA Eligible Individuals (Sum of Rows 1 and 5-17)	 

c. Homeless Individuals Summary

In Chart c, indicate the number of HOPWA eligible individuals reported as homeless in Chart b, Row 5 who are also identified as 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, Row 5.

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

Section 2. Beneficiaries

In Chart a., report the total number of HOPWA eligible individuals living with HIV/AIDS who received HOPWA housing subsidy assistance (as reported in Part 3A, Section 1, Chart a), and all associated members of their household who benefitted from receiving HOPWA housing subsidy assistance (resided with HOPWA eligible individuals).

Note: See definition of HOPWA Eligible Individual.

Note: See definition of Beneficiaries.

Note: See definition of Transgender.

Note: The sum of each of the Charts b & c on the following two pages equals the total number of beneficiaries served with HOPWA housing subsidy assistance as determined below in Chart a, Row 4 below.

a. Total Number of Beneficiaries Served with HOPWA Housing Subsidy Assistance

Individuals and Families Served with HOPWA Housing Subsidy Assistance	Total Number
1. Number of individuals with HIV/AIDS who qualified the household to receive HOPWA housing subsidy assistance (equals the number of HOPWA Eligible Individuals reported in Part 3A, Section 1, Chart a, Row 7)	 
2. Number of ALL other persons diagnosed as HIV positive who reside with the HOPWA eligible individuals identified in Row 1 and who benefitted from the HOPWA housing subsidy assistance	 
3. Number of ALL other persons not diagnosed as HIV positive who reside with the HOPWA eligible individual identified in Row 1 and who benefited from the HOPWA housing subsidy	 
4. TOTAL Number of ALL Beneficiaries Served with HOPWA Housing Subsidy Assistance (Sum of Rows 1, 2, & 3)	 

b. Age and Gender

In Chart b, indicate the Age and Gender of all beneficiaries as reported in Chart a. directly above. Report the Age and Gender of all HOPWA Eligible Individuals (those reported in Chart a, Row 1) using Rows 1-5 below and the Age and Gender of all other beneficiaries (those reported in Chart a, Rows 2 and 3) using Rows 6-10 below. The number of individuals reported in Row 11, Column E equals the total number of beneficiaries reported in Chart a, Row 4.

HOPWA Eligible Individuals (Chart a, Row 1)
		A.	B.	C.	D.	E.
		Male	Female	Transgender M to F	Transgender F to M	TOTAL (Sum of Columns A-D)
1.	Under 18	 	 	 	 	 
2.	18 to 30 years	 	 	 	 	 
3.	31 to 50 years	 	 	 	 	 
4.	51 years and Older	 	 	 	 	 
5.	Subtotal (Sum of Rows 1-4)	 	 	 	 	 
All Other Beneficiaries (Chart a, Rows 2 and 3)
		A.	B.	C.	D.	E.
		Male	Female	Transgender M to F	Transgender F to M	TOTAL (Sum of Columns A-D)
6.	Under 18	 	 	 	 	 
7.	18 to 30 years	 	 	 	 	 
8.	31 to 50 years	 	 	 	 	 
9.	51 years and Older	 	 	 	 	 
10.	Subtotal (Sum of Rows 6-9)	 	 	 	 	 
Total Beneficiaries (Chart a, Row 4)
11.	TOTAL (Sum of Rows 5 & 10)	 	 	 	 	 

c. Race and Ethnicity*

In Chart c, indicate the Race and Ethnicity of all beneficiaries receiving HOPWA Housing Subsidy Assistance as reported in Section 2, Chart a, Row 4. Report the race of all HOPWA eligible individuals in Column [A]. Report the ethnicity of all HOPWA eligible individuals in column [B]. Report the race of all other individuals who benefitted from the HOPWA housing subsidy assistance in column [C]. Report the ethnicity of all other individuals who benefitted from the HOPWA housing subsidy assistance in column [D]. The summed total of columns [A] and [C] equals the total number of ALL

Beneficiaries reported above in Section 2, Chart a, Row 4.

Category		HOPWA Eligible Individuals		All Other Beneficiaries
		[A] Race [all individuals reported in Section 2, Chart a, Row 1]	[B] Ethnicity [Also identified as Hispanic or Latino]	[C] Race [total of individuals reported in Section 2, Chart a, Rows 2 & 3]	[D] Ethnicity [Also identified as Hispanic or Latino]
1.	American Indian/Alaskan Native	 	 	 	 
2.	Asian	 	 	 	 
3.	Black/African American	 	 	 	 
4.	Native Hawaiian/Other Pacific Islander	 	 	 	 
5.	White	 	 	 	 
6.	American Indian/Alaskan Native & White	 	 	 	 
7.	Asian & White	 	 	 	 
8.	Black/African American & White	 	 	 	 
9.	American Indian/Alaskan Native & Black/African American	 	 	 	 
10.	Other Multi-Racial	 	 	 	 
11.	Column Totals (Sum of Rows 1-10)	 	 	 	 
Data Check: Sum of Row 11 Column A and Row 11 Column C equals the total number HOPWA Beneficiaries reported in Part 3A, Section 2, Chart a, Row 4.

*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 subsidy assistance.

Data Check: The total number of households served with HOPWA housing subsidy assistance should equal Part 3C, Row 7, Column [1] and Part 3A, Section 1, Chart a (Total HOPWA Eligible Individuals Served with HOPWA Housing Subsidy Assistance).

Note: Refer to https://www.huduser.gov/portal/datasets/il.html for information on area median income in your community.

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

Part 3: Summary Overview of Grant Activities

B. Sources of Leveraging and Program Income

1. Sources of Leveraging

Report the source(s) of cash or in-kind leveraged federal, state, local or private resources identified in the grant proposal/renewal application and used in the delivery of the HOPWA program and the amount of leveraged dollars. In Column [1], identify the type of leveraging. Some common sources of leveraged funds have been provided as a reference point. You may add Rows as necessary to report all sources of leveraged funds. Include Resident Rent payments paid by clients directly to private landlords. Do NOT include rents paid directly to a HOPWA program as this will be reported in the next section. In Column [2] report the amount of leveraged funds expended during the operating year. Use Column [3] to provide some detail about the type of leveraged contribution (e.g., case management services or clothing donations). In Column [4], check the appropriate box to indicate whether the leveraged contribution was a housing subsidy assistance or another form of support.

a. Source of Leveraging Chart

[1] Source of Leveraging	[2] Amount of Leveraged Funds	[3] Type of Contribution	[4] Housing Subsidy Assistance or Other Support
Public Funding
Ryan White-Housing Assistance			☐Housing Subsidy Assistance ☐Other Support
Ryan White-Other			☐Housing Subsidy Assistance ☐Other Support
Housing Choice Voucher Program			☐Housing Subsidy Assistance ☐Other Support
Low Income Housing Tax Credit			☐Housing Subsidy Assistance ☐Other Support
HOME			☐Housing Subsidy Assistance ☐Other Support
Continuum of Care			☐Housing Subsidy Assistance ☐Other Support
Emergency Solutions Grant			☐Housing Subsidy Assistance ☐Other Support
Other Public:			☐Housing Subsidy Assistance ☐Other Support
Other Public:			☐Housing Subsidy Assistance ☐Other Support
Other Public:			☐Housing Subsidy Assistance ☐Other Support
Other Public:			☐Housing Subsidy Assistance ☐Other Support
Other Public:			☐Housing Subsidy Assistance ☐Other Support
Private Funding
Grants			☐Housing Subsidy Assistance ☐Other Support
In-kind Resources			☐Housing Subsidy Assistance ☐Other Support
Other Private:			☐Housing Subsidy Assistance ☐Other Support
Other Private:			☐Housing Subsidy Assistance ☐Other Support
Other Funding
Grantee/Project Sponsor (Agency) Cash			☐Housing Subsidy Assistance ☐Other Support
Resident Rent Payments by Client to Private Landlord
TOTAL (Sum of all Rows)

2. Program Income and Resident Rent Payments

In Section 2, Chart a, report the total amount of program income and resident rent payments directly generated from the use of HOPWA funds, including repayments. Include resident rent payments collected or paid directly to the HOPWA program. Do NOT include payments made directly from a client household to a private landlord.

Note: Please see report directions section for definition of program income. (Additional information on program income is available in the HOPWA Grantee Oversight Resource Guide).

1. Total Amount Program Income and Resident Rent Payment Collected During the Operating Year

Program Income and Resident Rent Payments Collected		Total Amount of Program Income (for this operating year)
	Program income (e.g. repayments)	     
	Resident Rent Payments made directly to HOPWA Program	     
	Total Program Income and Resident Rent Payments (Sum of Rows 1 and 2)	     

2. Program Income and Resident Rent Payments Expended to Assist HOPWA Households

In Chart b, report on the total program income and resident rent payments (as reported above in Chart a) expended during the operating year. Use Row 1 to report Program Income and Resident Rent Payments expended on Housing Subsidy Assistance Programs (i.e., TBRA, STRMU, PHP, Master Leased Units, and Facility-Based Housing). Use Row 2 to report on the Program Income and Resident Rent Payment expended on Supportive Services and other non-direct Housing Costs.

Program Income and Resident Rent Payment Expended on HOPWA programs		Total Amount of Program Income Expended (for this operating year)
1.	Program Income and Resident Rent Payment Expended on Housing Subsidy Assistance costs	     
2.	Program Income and Resident Rent Payment Expended on Supportive Services and other non-direct housing costs	     
3.	Total Program Income Expended (Sum of Rows 1 and 2)	     

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

Note: See definition section for more information about Adjustment for Duplication.

Data Check: Data in this section is summarized from all project sponsors PART 5A-E submissions and therefore should match the combined total for those submissions. HOPWA housing subsidy assistance, supportive services, and housing placement activities are measured in households served while housing development activities are measured in units developed.

1. Performance and Expenditure Information by Activity Type

HOPWA Housing Subsidy Assistance		[1] Outputs: Number of Households	[2] Outputs: 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/Leased units	     	     
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.	Permanent Housing Placement Services	     	     
6.	Adjustment for duplication (subtract)	     
7.	TOTAL HOPWA Housing Subsidy Assistance (Column 1 equals sum of Rows 1-5 minus Row 6; Column 2 equals the sum of Rows 1-5)	     	     
Housing Development (Construction and Stewardship of Facility-Based Housing)		[1] Outputs: Number of Housing Units	[2] Outputs: Amount of HOPWA Funds Expended
8.	Facility-Based Units; Capital Development Projects not yet opened	     	     
9.	Stewardship units subject to 3- or 10- year use periods	     
10.	TOTAL Housing Development (Sum of Rows 8 and 9)	     	     
Supportive Services		[1] Outputs: Number of Households	[2] Outputs: Amount of HOPWA Funds Expended
11a.	Supportive Services provided by project sponsors that also delivered HOPWA housing assistance (as reported in Part 5D, 1a.)	     	     
11b.	Supportive Services provided by project sponsors that only provided supportive services (as reported in Part 5, D, 1b)	     	     
12.	Adjustment for duplication (subtract)	     
13.	TOTAL Supportive Services (Column 1 equals Sum of Rows 11a. & 11b. minus Row 12; Column 2 equals Sum of Row 11a & 11b)	     	     
Housing Information Services		[1] Outputs: Number of Households	[2] Outputs: Amount of HOPWA Funds Expended
14.	Housing Information Services	     	     
15.	TOTAL Housing Information Services	     	     
Grant Administration and Other Activities		[1] Outputs: Number of Households	[2] Outputs: Amount of HOPWA Funds Expended
16.	Resource Identification to establish, coordinate and develop housing assistance resources		     
17.	Technical Assistance (if approved in grant agreement)		     
18.	Project Outcomes/Program Evaluation (if approved in grant agreement)		     
19.	Grantee Administration (maximum 3% of total of HOPWA grant)		     
20.	Project Sponsor Administration (maximum 7% of portion of HOPWA grant awarded)		     
21.	Other Activity (if approved in grant agreement). Specify:      	     	     
22.	TOTAL Grant Administration and Other Activities (Sum of Rows 16-21)	     	     
TOTAL Expended			[2] Amount of HOPWA Funds Expended
23.	TOTAL Expenditures (Sum of Rows 7, 10, 13, 15 & 22)		     

End of Part 3

Part 4: Summary of Performance Outcomes

Housing Stability, Prevention of Homelessness, and Access to Care

In Column [1], report by type the total number of households that received HOPWA housing subsidy assistance. In Column [2], enter the number of households continuing to access each type of HOPWA housing subsidy assistance into the following year. In Column [3], report the housing status of all households that exited the program.

Note: Refer to the destination codes that appear in Part 6: Appendix: Worksheet on Determining HOPWA Outcomes and Connections with HMIS.

Data Check: The sum of Columns [2] (Number of Households Continuing) and [3] (Exited Households) equals the total households reported in Column [1].

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

1. Permanent Housing Assistance

	[1] Output: Total Number of Households	[2] Assessment: Number of Households that Continued Receiving HOPWA Housing Subsidy 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] Output: Total Number of Households	[2] Assessment: Number of Households that Continued Receiving HOPWA Housing Subsidy 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 Housing 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 receiving transitional/short-term housing assistance 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 total households reported as served with STRMU in Column [1] equals the total reported in Part 3C, Chart 1, Row 4, Column [1].

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

Assessment of Households that Received STRMU Assistance

[1] Output: Number of Households	[2] Assessment: 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 Subsidy 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. Total Number of Households

Line [1]: For project sponsors that provided HOPWA housing subsidy assistance during the operating year, identify in the appropriate row the number of households that received HOPWA-funded housing subsidy assistance (TBRA, STRMU, Facility-Based, Permanent Housing Placement Services and Master Leasing) and HOPWA-funded case management services. Use Row c to adjust for duplication among the service categories and row d to provide an unduplicated household total.

Line [2]: For project sponsors that did NOT provide HOPWA housing subsidy assistance identify in the appropriate row, the number of households that received HOPWA-funded case management services.

Note: These numbers will help you to determine which clients to report Access to Care and Support Outcomes for and will be used by HUD as a basis for analyzing the percentage of households who demonstrated or maintained connections to care and support as identified in Chart 1b below.

Total Number of Households
For Project Sponsors that provided HOPWA Housing Subsidy Assistance: Identify the total number of households that received the following HOPWA-funded services:
Housing Subsidy Assistance(duplicated)- TBRA, STRMU, PHP, Facility-Based Housing, and Master Leasing
Case Management
Adjustment for duplication (subtraction)
Total Households Served by Project Sponsors with HOPWA Housing Subsidy Assistance (Sum of Rows a & b minus Row c)
For Project Sponsors did NOT provide HOPWA Housing Subsidy Assistance: Identify the total number of households that received the following HOPWA-funded service:
Case Management
Total Households Served by Project Sponsors without Housing Subsidy Assistance

1b. Status of Households Accessing Care and Support

Column [1]: Of the households identified as receiving services from project sponsors that provide HOPWA housing subsidy assistance as identified in Chart 1a, Row 1d above, report the number of households that demonstrated access or maintained connections to care and support within the operating year.

Column [2]: Of the households identified as receiving services from project sponsors that did NOT provide HOPWA housing subsidy assistance as reported in Chart 1a, Row 2b, report the number of households that demonstrated improved access or maintained connections to care and support within the operating year.

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

Categories of Services Accessed	[1] For project sponsors that provided HOPWA housing subsidy assistance, identify the households who demonstrated the following:	[2] For project sponsors that did NOT provide housing subsidy assistance, identify the households who demonstrated the following:	Outcome Indicator
1. Has a housing plan for maintaining or establishing stable on-going housing	     	     	Support for Stable Housing
2. Had contact with a case manager/benefits counselor consistent with the schedule specified in client’s individual service plan (may include leveraged services such as Ryan White Medical Case Management)	     	     	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 1b, Row 4: 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 1b, Row 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

1c. Households that Obtained Employment

Column [1]: Of the households identified as receiving services from project sponsors that provided HOPWA housing subsidy assistance as identified in Chart 1a, Row 1d above, 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 households identified as receiving services from project sponsors that did NOT provide HOPWA housing subsidy assistance as reported in Chart 1a, Row 2b, 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 programs, employment assistance, education or related case management/counseling services.

Note: This includes jobs created by project sponsors or obtained from an outside agency.

Note: Do not include jobs that resulted from leveraged job training, employment assistance, education or case management/counseling services.

Categories of Services Accessed	[1 For project sponsors that provided HOPWA housing subsidy assistance, identify the households who demonstrated the following:	[2] For project sponsor that did NOT provide HOPWA housing subsidy assistance, identify the households who demonstrated the following:
Total number of households that obtained an income-producing job	     	     

End of Part 4

Part 5A: Summary of Each Project Sponsor Information

This section requests information on direct HOPWA service delivery activities for client households by organization or agency. For each organization or agency designated or selected to serve as a project sponsor, please complete the entirety of Parts 5A-E. Order the report as Part 5A-E for Project Sponsor 1, then Part 5A-E for Project Sponsor 2, etc.

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

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

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)	     
Congressional District of Sponsor’s Business Address	     
Congressional District(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 ☐

Part 5: Summary of Each Project Sponsor Information

B. Rental Assistance, Short-Term Rent, Mortgage and Utility Assistance Programs and Permanent Housing Placement Assistance

1. Rental Assistance (RA)

Enter the total number of households served in Column [1] and the amount of HOPWA funds expended Column [2] by the project sponsor on RA.

HOPWA Housing Subsidy Assistance Category: RA		[1] Output: Number of Households Served	[2] Output: 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.	Direct program delivery costs (e.g., program staff time)		   
d.	TOTAL Rental Housing Assistance (For Column [1] sum of Row a. & Row b., for Column [2] sum of rows a – c)	   	   

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

In Row a, enter the total number of households served and the amount of HOPWA funds expended by each project sponsor on Short Term Rent, Mortgage, and Utility assistance (STRMU).

In Row b, enter the total number of STRMU assisted households that received assistance with mortgage costs only (no utility costs) and the amount expended by the project sponsor assisting these households. In Row c, enter the total number of STRMU assisted households that received assistance with both mortgage and utility costs and the amount expended by the project sponsor assisting these households. In Row d, enter the total number of STRMU assisted households that received assistance with rental costs only (no utility costs) and the amount expended by the project sponsor assisting these households. In Row e, enter the total number of STRMU assisted households that received assistance with both rental and utility costs and the amount expended by the project sponsor assisting these households. In Row 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 the project sponsor assisting these households. In row g, report the amount of STRMU funds expended to support direct program costs such as program operation staff.

Data Check: The total households reported as served with STRMU in Row a, column [1] and the total amount of HOPWA funds reported as expended in Row a, column [2] equals the household and expenditure total reported for STRMU in Part 3C, Chart 1, Row 4.

Data Check: The total number of households reported in Column [1], Rows b, c, d, e, and f. should equal the total number of STRMU households reported in Column [1], Row a. The total amount reported as expended in Column [2], Rows b, c, d., e, f, and g. should equal the total amount of STRMU expenditures reported in Column [2], Row a.

Housing Subsidy Assistance Categories (STRMU)		[1] Output: Number of Households Served	[2] Output: Total HOPWA Funds Expended on STRMU during Operating Year
a.	Total Short-term mortgage, rent and/or utility (STRMU) assistance	   	   
b.	Of the total STRMU reported on Row a, total who received assistance with mortgage costs ONLY.	   	   
c.	Of the total STRMU reported on Row a, total who received assistance with mortgage and utility costs.	   	   
d.	Of the total STRMU reported on Row a, total who received assistance with rental costs ONLY.	   	   
e.	Of the total STRMU reported on Row a, total who received assistance with rental and utility costs.	   	   
f.	Of the total STRMU reported on Row a, total who received assistance with utility costs ONLY.	   	   
g.	Direct program delivery costs (e.g., program operations staff time)		   

3. Permanent Housing Placement Services

In Row a, Column [1] report the households served with HOPWA-funded Permanent Housing Placement Assistance and in Row a, Column [2] report the HOPWA funds expended on Permanent Housing Placement Services. Use Row b, to report on direct program delivery costs used to operate the Permanent Housing Placement Program. Use Row c, to report household and expenditure totals for Permanent Housing Placement Services.

HOPWA Housing Subsidy Assistance Category: Permanent Housing Placement Assistance		[1] Output: Number of Households Served	[2] Output: Total HOPWA Funds Expended during Operating Year by Project Sponsor
a.	Permanent Housing Placement Services	   	   
b.	Direct program delivery costs (e.g., program staff time)		   
c.	TOTAL Permanent Housing Placement Services (sum of Rows a. and b.)	   	   

Part 5: Summary of Each Project Sponsor Information

C. Facility-based Housing Assistance

Complete one Part 5C for each facility developed and/or supported through HOPWA funds.

Do not complete this Chart for programs originally developed with HOPWA funds but no longer supported with HOPWA funds. 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 Section 5E: Annual Report of Continued Usage for HOPWA Facility-Based Stewardship Units (ONLY).

Complete Charts 1a, Project Site Information, and 1b, Type of HOPWA Capital Development Project Units, for all Development Projects, including facilities that were past development projects, but continued to receive HOPWA operating dollars this reporting year.

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

Note: If units are scattered-sites, report on them as a group and under type of Facility write “Scattered Sites.”

Type(s) of Development this operating year		HOPWA Funds Expended this operating year (if applicable)	Non-HOPWA funds Expended (if applicable)	Name of Facility:      
New construction		$     	$     	Type of Facility [Check only one box.] ☐ 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 HOPWA Capital Development Project (For Current or Past Capital Development Projects that receive HOPWA Operating Costs this reporting year)

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 – Mobility Units - Sensory Units
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 or Operated by Project Sponsor

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.

Indicate the type and number of housing units in the facility, including master leased units, project-based or other scattered site units leased by the organization, categorized by the number of bedrooms per unit. Note: The number units may not equal the total number of households served. Please complete separate charts for each housing facility assisted. Scattered site units may be grouped together on one page.

a. Check one only.

☐ Permanent Supportive Housing Facility/Units

☐ Short-term Shelter or Transitional Supportive Housing Facility/Units

b. Type of Facility

Complete the following Chart for all facilities leased, master leased, project-based, or operated with HOPWA funds during the reporting year.

Name of Project Sponsor/Agency Operating the Facility/Leased Units:    

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/Studio/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, project based or other scattered site units leased by the organization.

Housing Assistance Category: Facility Based Housing		Output: Number of Households Served	Output: 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 Each Project Sponsor Information

D. Supportive Services and Other Activities

In this section, report on the use of HOPWA funds for supportive services and other activities.

In Chart 1, if the project sponsor provided both HOPWA funded supportive services AND HOPWA housing subsidy assistance check Box 1a. If the project sponsor provided supportive services but did not also provide HOPWA housing subsidy assistance, check Box 1b. If the project sponsor did not provide any HOPWA funded supportive services, check Box 1c.

1. Type of Project Sponsor (Check one only)

a. Supportive Services are provided by project sponsor that also delivered HOPWA housing subsidy assistance (complete Chart 2 and 3)	☐
b. Supportive Services provided by project sponsor who did NOT also provide HOPWA housing subsidy assistance (complete Chart 2 and 3)	☐
c. Project sponsor does not provide HOPWA supportive services (complete only Chart 3 only)	☐

2. Listing of Supportive Services paid for with HOPWA funds provided by Project Sponsor Agency

In Chart 2, project sponsors who provided HOPWA supportive services during the operating year (checked off Box 1a or 1b in Chart 1) should report the total of all households and expenditures for each type of HOPWA-funded supportive service delivered. Use Row 16 to adjust for duplication and Row 17 to provide an unduplicated household count. All project sponsors who provided supportive services with HOPWA funds during the operating year should report by supportive services activity type the number of households served and HOPWA dollars expended.

Note: Every project sponsor who checked off Box 1a or 1b above should report households served and funds expended by supportive service type in Chart 2 below.

Supportive Services		[1] Output: Number of Households	[2] Output: Amount of HOPWA Funds Expended
1.	Adult day care and personal assistance	   	   
2.	Alcohol and drug abuse services	   	   
3.	Case management	   	   
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 (Sum of Rows 1-14)	   
16.	Adjustment for Duplication (subtract)	   
17.	TOTAL Households receiving Supportive Services (unduplicated) (Column [1] equals Row 15 minus Row 16; Column [2] equals sum of Rows 1-14)	   	   

3. Listing of Housing Information Services, Grant Administration, and Other Activities paid for with HOPWA funds

In Chart 3, all project sponsors should report Housing Information Services and Grant Administration and Other activities, as applicable. Use Chart 3, Rows 18 and 19 to report the number of unduplicated households receiving HOPWA housing information services and HOPWA dollars spent providing housing Information services. Use Rows 20 through 24 to report HOPWA expenditures on other activities including Grant Administration.

Note: The sum total reported in Row 26 includes the total supportive services dollars reported in Chart 2 Row, 17.

Housing Information Services		[1] Output: Number of Households	[2] Output: Amount of HOPWA funds Expended
18.	Housing Information Services	   	   
19.	TOTAL Housing Information Services	   	   
Grant Administration and Other Activities		[1] Output: Number of Households	[2] Output: Amount of HOPWA funds Expended
20.	Resource Identification to establish, coordinate, and develop housing assistance resources		     
21.	Technical Assistance to Community Residences		     
22.	Project Outcomes/Program Evaluation (if approved)		     
23.	Project Sponsor Administration (maximum 7% of portion of HOPWA grant awarded)		     
24.	Other Activity (if approved in grant agreement) Specify:      	     	     
25.	TOTAL Grant Administration and Other Activities	     	     
26.	TOTAL Supportive Services and Grant Administration Expenditures (Sum of Chart 2, Row 17 and Chart 3, Rows 19 and 25)		     

Part 5: Summary of Each Project Sponsor Information

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

The Annual Report of Continued Usage for HOPWA Facility-Based Stewardship Units is to be used in place of Section 5C of the APR if the facility was acquired, rehabilitated or constructed/developed in part with HOPWA funds but NO HOPWA funds were expended during the operating year. Scattered site units may be grouped together on one page.

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 (10) years. If non-substantial rehabilitation funds were used they are required to operate for at least three (3) years. Stewardship begins once the facility is put into operation.

Note: See definition of “Stewardship Units”.

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 Non-HOPWA Expenditures

Facility Name:      	Number of Stewardship Units Developed with HOPWA funds	Amount of Non-HOPWA Funds Expended in support of the Stewardship Units during the Operating Year
Total Stewardship Units (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	     

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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Previous editions are obsolete form HUD-40110-C (Expiration Date: XX/XX/XXXX)