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11/30/2009) No, OMB Approval 2506-0145

U. S. Department of Housing and Urban Development Offtce of CommunityPlanning and Development

Grant Year 2006- 2fr87

GGPV

Annual ProgressReport (APR)


for SupportiveHousingProgram ShelterPlusCare
and Section8 Moderate Rehabilitation for Single Room Occupancy Dwellings (SRO) Program

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Public reporting burden for this collection ofinformation is estimated to average33 hours per response,including the time for reviewing instructions, searching existing data sources,gathering and maintaining the data needed,and completing and reviewing the collection of information. This agency may not conduct or sponsor, and a personis not requiredto respondto, a collectionofinformation unlessthat collection displaysa valid OMB control number.

General Instructions Purpose. The Annual ProgressReport (APR) is a reporting tool that HLID usesto track program progressand accomplishmentsand inform the Department's competitive processfor homelessassistance funding. Filing Requirements. Recipientsof HUD's homeless assistance srants must submit 2 APR'S to I{UD within 90 days after the end of each operating Year. One copy of the report must be submitted to the Community planning uoa n.*top-.ot (CPD) Division Director in the local HUD Field Office responsiblefor managing the grant. The other copy must be submitted to HLID Headquarters,Deparlment of Housing and Urban Development,Attn: APR Data Editor, BoomjieZ,451 7h Sheet, SW, Washington, DC. 20410. Failure to submit an APR will delay receiving grant funds and may result in a determination of lack of capacity for future funding. An APR must be submitted for eachoperating year in which HIID funding is provided. Granteesthat received SHP funding for new construction, acquisition, or rehabilitation are required to operatetheir facilities for 20 yeats. They must submit an APR 90 days after the end ofthe first operating year and every year throughout the 20 years. A separatereport must be submitted for each HUD grant received. For Shelter Plus Care (S+C), a separateApR must be submitted for each S+C component. For those granteesreceiving an extension,a separaterepoft covering that period must be submitted (seeExtension below). Recordkeeping. Granteesmust collect and maintain information on eachparlicipant in order to complete an ApR. Optional worksheetsare attached. The worksheetsmay be used to record information manually or to design a iomputerized system to store and tabulatethe informahon. The worksheetsshould not be submitted to HUD with the AFR. organization of the Report. The APR is organized in the following manner: Part I: Project Progress.This portion of the reporl describes progressin moving homeless the personsto self-sufficiency, documenting servicesreceived, listing project goals, and accountingfor beds/units. Part II: Financial Information. and SRO. This portion of the report is completedby all granteesreceiving {irnding under SHp, S+C,

Final Assembly of Report. After the entire report is assembled, nurhberevery page sequentially. Mark any questionsthat do not apply to your program with "N/A" for not applicable. (See Special Instructions for SSO Projects below.) Definitions of Client/Ilousehold Types. Each clientihouseholdtype is defined below. Note that a client's client/household type should be basedon the client's age and/or householdcomposition at the program entty date closest to the start ofthe operating year. tr'amilies - A family is a household composedof fwo or more related persons, at least one of who is a child accompanied by an adult or a juvenile parent. Singles not in Families * Personsnot accompaniedby children, including pregnantwomen not accompaniedby other children and unaccompaniedyouth, are singles not in families. When two adults or two unaccompaniedyouth present together for services,eachperson should be counted in singlesnot in families.. Clients' household statusshould be determinedbased on their household composition at the program entry date closestto the start of the operating year. This meansthat pregnant women expectedto give birth during their program stay should still be counted as singlesnot rn families. Adults in Families - Within a family, an adult is any person 18 years of age or older. For the purposesof APR reporting, the determination of whether a person is an adult in family shouid be made basedon their age and householdcomposition at the program entry date closest to the start ofthe operatingyear. Children in tr'amilies- Children in Familiesare dehnedas childrenunder the ageof 18 accompanied one or more by adults (parent, relative or guardian). Children in families also inciude both a juvenile parent and the parent's child(ren). For the purposesof APR reporting, the determinationof whether a person is a child in family should be made based on their age and household composition at the program entry date closestto the start of the operating year. For example,
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clients who are less than 18 years of age on the first day of the operating year or at program entry (if they enteredduring the operating year) should be counted as children even ifthey turn 18 during the course ofthe operating year. Persons in Families - Personsin families includes adults in families and children in families.

Other Key Definitions. The following tems are used in the APR. As indicated, in some cases,terms are applied differently dependingon whether the funding is from SHP, S+C, or SRO. personas "an unaccompanied Chronically homelessperson - HUD definesa chronicallyhomeless homeless individual with a disabling condition who has either been continuously homelessfor a year or more OR has had at least four (4) episodes homelessness the past three (3) years." To be considered of in chronically homeless, personmust havebeen on a the streetsor in an emergencyshelter (i.e., not in transitional housing) during these stays. HUD's definition of a chronicallyhomeless personis basedon the following components: o Unaccompanied homelessindividual: an unaccompanied homelessindividual has the samecharacteristics of a Singlenot in a Family (describedabove). . Disabling condition: seethe instructions under disabling condition (below) to determinewhether a client is disabled. Did not leave the program - This term refers to clients who were in the program on the last day of the operating year. Disabling condition - HUD definesa disabling condition as: (1) A disability as definedin Section223 of the Social Security Act; (2) a physical, mental, or emotional impairment which is (a) expectedto be of long-continued and indefinite duration, (b) substantiallyimpedes an individual's ability to live independently, and (c) of such a nature that such ability could be improved by more suitable housing conditions; (3) a developmental disability as dehned in section 102 of the Developmental Disabilities Assistanceand Bill of Rights Act; (4) the diseaseof acquired immunodeficiency syndrome or any conditions arising from the etiological agency for acquired immunodeficiency slmdrome; or (5) a diagnosable substance abusedisorder. Entered the program - Entered the program refers to the first day a client receives services. For a residentialprograrn, this date would representthe first day of residencein the program's housing. For services,this date may representthe day of program enrollment, the day a service was provided, or the first date of a period of continuous participation in a service (e.g.,daily, weekly, or monthly). For S+C and SRO programs, the program entry date is the date that the parlicipant starts to receive rental assistance. For S*C, servicesprovided prior to this point are recognized as necessaryfor outreach./enrollment and are eligibie to count as match. An Extension APR applies to SHP and S+C granteesthat requestedand received an extension of their grant term from the HIID field office. The only difference between an APR for the extension period and the regular APR (besidesthe amount of time covered) is the signaturepage. Granteesshould circle "yes" to indicate the APR is for an extension period and circle the operating year for which the report is an extension.For example, if the granteeis extending year 3, the granteeshould submit an APR as usual for year 3 and submit another APR for the extensionperiod, indicating the secondis an extension and also circling year 3 on the signaturepage. Grantee meansa direct recipient of the HIID award. Left the program - Left the program refers to the last day a client receivesservices. For a residential prograrrl this date would representthe last day of residencein the program's housing. For services,the exit date may representthe last day a servicewas provided or the last date ofa period ofcontinuous service. Ifa client leavesthe programtemporarily(e.g., for a hospitalization) but is expected to return within 30 days, do not count that client as having left the program. For S+C programs, the program exit date refers to the date the participant stops receiving rental assistance and is not expectedto return to S+C assistedhousing. Ifthe participant returns to S+C assistedhousing within 90 days, the person should not be consideredas exitrng from the program. If the person retums to S+C assistedhousing after 90 days, that person is considereda new participant. The worksheet is designedto capture this information.
HUD-40118

Match for S+C is the value of supportive servicesreceived by participants in the S+C project which, in the aggregate, must at least equal the value of the S+C rental assistance provided over the life of the project. For SHP, match is cash used to provide the grantee'sportion ofacquisition, rehabilitation, new conshuction, operations and supportive services expenses. Operating year - For SHP progranr, the frst operating year begins after developmentactivities for acquisition, rehabilitation, and new construction are complete, after a copy of the Certificate of Occupancy is sent to the local HUD office, and when the first participant is acceptedinto the project. For projects without acquisition, rehabilitation, or new construction,the operating start date begins when the granteeacceptsthe hrst participant. For dedicatedHMIS projects, the operating year begins when any eligible cost included in the approvedproject budget is incurred. For S+e igp,4, PRA and TRA components),the first operating year begins on the date HUD signs the grant agreement. For S+C/SRO and for Sec. 8 SRO, the first operating year begins with the effective date of the Housing AssistanceparnnentsfHAp) Contract. To determine which operating year to circle on the APR cover page, begin counting from the initial grant operating start date and include renewal grants. For example, a project receiving an initial grant for three years ur,d u ..n"-ul grant for two years would circle years 1, 2, and3 respectively on the APR cover sheetfor the initial grant and would circle 4 and 5 respectively for the renewal grant. For any future renewal grants,the granteewould begin by circling 6 on the ApR cover sheet. Participants - The term participant refers to Singles not in Families and Adults in Families as defined above. particioant does not in6lude children or caregiverswho live with the adults assisted. Project Sponsor meansthe organization responsible for canying out the daily operation of the project, if the organization is an entity other than the grantee.

Special Instructions for Supportive Service Onlv (SSO) Proerams. SSo grantees should completeall questions, unless a written agreementhas been reachedwith the field office conceming which questionscan be answeredusing estimates, or in rare instances,skipped. Below is an exampleof how informationcould be derivedin a large,single-service SSOproject: A grantee/sponsor staff member could be assignedto collect information from the organizationshousing the participants. The staff person would contact theseindividual organtzationsto requestinformation regarding the personsin that facility that use the service. For participants living on the street,the grantee/projectsponsormay provide estimates. Information could be collected for eachparticipant or for participants receiving servicesat a point-in-time. If estimatesor point-in-time counts are used, the method used must be describedin the APR and the documentationkept on file. As with all projects funded under IIID's homelessness assistance grants, granteesoperating SSO projects are expectedto complete all APR questionsthat are applicable to them. Note that all projects have been awarded funds as a result of responding to the program goals of assistinghomelesspersonsobtain/remainin permanenthousing and increasetheir skil1sand income. The APR documentstheir progress in meeting these goals. In some circumstancesfield offices and granteesmay sign a written agreementconcerningquestionsthat can be answeredusing estimates,or in rare instances,skipped. Seethe special instructions below for repofting on special tlpes of projects, such as outreachonly projects, projects providing servicesto children only, and transportation,med.ical,dental, and other single, shortduration service proj ects. SSO programs are a third priority for local HMIS implementation, following emergencyshelters,transitional housing programs, oufreachprograrns,and permanentsupportive housing progranls. Once SSO progralns are included in the HMIS, SSO grantees will be able to answer all APR questionsusing their HMIS data. SSO granteesthat are not yet participating in HMIS will need to collect data to answer the APR questionsusing the special instructions provided above. Outreach Only Projects. Projectswhich are solely devotedto sheetoutreachand connectionto housi4gand services are not required to hack participants beyond their contact with personson the street. It is sufficient for theseprojects to enter
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forquestions 5-9 are allowed, giventhat infornationonquestions 1-10(skippingquestions11-13 and 17). Estimates personal questions. participants may be reluctant to answer Answering the questionswili demonstratethat the granteeis serving the appropriatenumber of people, providing basic demographic information for Congress,demonstratingthat homelesspersonsare being sewed, demonstratingthe types of housing parlicipants are corurectedto, and the type of servicesthey are receiving. Hotline Projects. Hotline servicesare similar to outreach only projects, but contact between grantee and participant is often of very short duration - people enter and leave the program nearly simultaneously. It is sufficient for these projects to answer questions1-5 (skipping4), 10, and 14-19(skipping 17). ProjectsProviding Services Children Only. Projects that provide child care, after school care, counseling for children, To etc. make an important contribution toward moving a family out of homelessness. While the main focus of the project is providing servicesto the children, it is the adults who are reported on in questions6-16 of the APR. Like all other projects, this type is also targeted toward getting the families into housing and increasing the families' incomes. Granteesmay skip question 9; all other questionsshould be answered(except 17). Transportation, Medical, Dental, and Other Single, Short-Duration Service Projects. Somegrantees provide a single service of fairly short duration focused ONLY indirectly on assistinghomelesspersonsto obtain/remain in permanent housing and increasetheir skills and incomes. It is sufficient for theseprojects to enter information on questions l-10 and 1419 (question 17 may be skipped). However, with transportation services,it is unreasonableto think that someonewould have to give their age, race, and ethnicity to a bus driver to get a ride a few blocks. For these serrrices, provide a narrative, which gives the numb'erof rides given during the operating year, and provides estimates on the above statisticsbasedon the population that utilizes the service. Special Instructions For Safe Haven (SH) Proiects. Crrantees shouldreport on a1lparticipantsservedduring the operating year. Note: this is a changefrom prior instructions where granteeswere instructed to report on the first 25 participants served.

Special Instructions for HomelessManagement Information System (HMIS) Proiects. HMISgrantees


should fill out the cover sheetof the APR, Part II Financial Information, and the HMIS Activities section.

HUD-40118

THIS PAGE - TO BE COMPLETED BY ALL GRANTEES


Grantee:

Number: HLrDGrantor Project

Cityand Countyof San Francisco


ProjectSponsor:

cAo1 8501009
ProjectName:

Swordsto Plowshares
Operating Year: (Circle the operating year being reported on)

Veterans Academvat the Presidio


Reporting Period: (month/day/year)

!t lz !: !+ ;1s no Ez tra ns nro f lll f l 1 2n l 3 [ 1 4 n rs n r0 l rz l ra n rs n zo


Indicateifextension: ! Y"s X No Indicate if renewal: X Yes fl r.to PreviousGrantNumbersfor this oroiect:

fiom: July 1,2006

to:June 30,2007

cAo1B40'1020 cAo1 8301028

Check the component for the program on which you are reporting.

Supportive Housing Program (SHP) ! fi Transitional Housing PermanentHousing for Homeless Personswith Disabilities SafeHaven Innovative Supportive Housing Supportive Services Only HMIS

Shelter PIus Care (S+C) ! n n n Tenant-basedRental Assistance(TRA) Sponsor-based (SRA) RentalAssistance Project-basedRental Assistance(PRA) SingleRoom Occupancy(SRO)

Section ModerateRehabilitation 8 n SingleRoomOccupancy (Sec.8 SRO)

n n n n

Summary theproject:(One twosentences a description population, of or with of number served accomplishmentsoperating and year) this We serve100 singleadultveterans with disabilities with histories homelessness, of chronichomelessness, substance abuseand mentalhealthissues. We served100 unduplicated year. The projectenjoyedsignificant residents duringthe operating successin exceeding objectives.Havingserveda totalof 207 individuals all years,72Vo those duringthe first7 operating of remainhere or else have moved intootherpermanent including homeownerships. the housingsituations, 3 Of initial100 residents, continuein residence 56 here or have movedinto otherpermanent housingsituations.Nearly halfof these207 veteransare deemedChronically Homeless. !00%of thosewith alcoholand/ordrug abuse/dependence issueshave accessedindividual groupharm reduction, or drug treatment, relapseprevention or period. 12-step meetings duringthis reporting
Name& Title of thePerson who cananswer questions aboutthis report:
Phone: (include area code) (415) 561-2610ext.30l

PaulGlennon, Assistant the Housing to Director.


Address:

Fax Number: (include areacode)

'104A Francisco. 94129 1030 Girard Road San CA pglen E-mail Address non@Stp-sf .org

(415)561-2615

HUD-401 18

I liereby certify that all the information stated herein is true and accurate. (l8U.S.C. 1001, prosecutefalseclaimsandstatements. Convictionmayresultincriminaland/orcivilpenalties. Warning: HUDwill 1010. l0l2: 31U.S.C. 3729. 3802
Name& Titleof Authorized Grantee Official: Signature Date: &

Mikyung Kim,SHP GrantsManager


NameandTitleof Authorized Project Official: Sponsor

-)n

MichaelBlecker, Executive Director

'stlo7

HUD-401l8

(EXCEPT HMIS) BY I. PAR.T TOEE COMPLETED ALL GRANTEES


GRANTEES,PLEASE SEE SPECIAL IIVSTRUCTIONSON PAGE 3 OF THE APR SSO

Part I: Project Frogress


1.
1Catl0n.

projected Level of F".ror6 to be served at a given point in time. (This infotmation comesfrom the most recentCoC
Number of SinglesNot in Families

ProiectedLevei Personsto be servedat a given point in time

Numberof Adultsin Families

Number of Children in Families

Number of Families

100

2.

Persons Served during the operating year.


Number of SinglesNot in Families Number of Adults in Famiiies Number of Children in Families Number of Families

a.

Number on the first day of the operating year Number entering program during the operating year Number who left the program during the operating year

97 0

0 0 0 0

0 0 0
U

0
0

b.

0
0

d.

Number in the program on the last day of the operating year (a+b-c):d

100

Explanatory notes: SeeDefinitions of Client/Household Types in the General Insfructions above to determine which clients should be counted as Singles Not in Famiiies, Adults in Families, and Children in Families. Note that this table does not account for changesin clienf&ousehold type that may occur during the course ofthe operating year. Instead, each client should be assigneda single client/household type based on the client's Itthisway,eachclientiscounted ageand/orhouseholdcomposttionattheprograntentrydateclosesttotheslartoftheoperatingyear. once in the table. oniy Use the following graphic and explanations to determine who shouid be counted in rows a-d:

on Client program firsldeyof in year,lefrduring the opBraling year:countin 2a and2c.


Clienl in program on firsl day of operating year and last day ofoperaling year count in 2a and 2d.

a,+
a4 Clieni entered and left progmm before siart of operating yean do not counl in question 2.

and Client entered leff progmm dunngoperatrng year countin 2b and2c. program enlered during Clienl year operating andslilljn program lastdayof yea[ on in count 2b and2d.

FiFt day of the operating year

Last day ofthe operaling yeat

Number on the first day of the operating year: This row includes all clients who enteredthe program before the frrst day of the operating year and did not leave the program untii after the first day ofthe operating year. b. Number entering the program during the operating year: This row includes all clients who enteredthe program on or after the first day of the operating year, up to and including the last day of the operating year. For clients with multiple program entry dates, use the entry date closestto the start ofthe operating year. Do not count the client more than once even ifhe/she enteredthe program more than once during the operating Year. Number who left during the operating year: This row includes all clients who left the program on or after the first day of the operating year, up to and including the last day of the operating year. For clients with multiple program exit dates,use the exit date HUD-40118

if he/sheexited the programmore than once during closestto the end of the operatingyear. Do not count the client more than once even the operating year. d. program as of the first Number in the program on the last day of the operating year: This row includesall clients who were in the during the operatingyearand who did not leave during the operatingyear. The number of day ofthe operatlngyear or who entered to clients or families in the program on the last day ofthe operatingyear is calculatedbasedon the responses rows 2a through 2c. For eachcolumn, add the number of clients or families in row 2a to the number of clients or families in row 2b and subtractthe number of clients or families in row 2c. Therefore,2d: 2a + 2b - 2c

3.

Project Capacity.
Number of SinglesNot in Families

Number of Adultsin Famifies

Number of Children in Families

Number of Families

a.

Number on the last day (from 2d, columns I and 4) Number proposedin application(from I a, columns I and 4) CapacityRate (divide abyb) - %

100 100
100 % ..'

0 0
0%

b. c.

Explanatory Notes: is for CoCapplication whichtheprogram reporting. Rowb refers themostrecent to

4.

Non-homelesspersons. This questionis to be completedfor Section8 SRO projects


| 0

personswere housedby the SRO program during the operatingyear? How many income-eligiblenon-homeless

5.

Age and Gender. Of those who entered the project during the operating year, how many people are in the followrng age and gendercategories? (from 2b, column1 SinslePersons
VL

Aee and over

Male

Female

0
z

b.
c. d.

5 1-61 31-50 18-30


17 and under

0 0 0 0
0

0 0 0 0 0
0

(from 2b, columns & 3) 2 Persons Families in

f.
g

62 and over

h.
l.

J.
1.

t.
m.

5l 61 3l -50 l 8 30 13-1'7 6-12 1-5 Under1

0
0

0 0
n

0 0

0 0 0 0 0

ExplanatoryNotes: year. Only clients duringtheoperating who entered program the in and not refers only to Singles in Families Persons Families This question to Persons should equal the be underSingle ofclientsreported in can criteria be counted thistable. Thetotalnumber who meetthese in should equal thesumof be to under Persons Families reported of 2b, reported question column1, Thetotalnumber clients in number 2b. 2 columns and3 in question 6 Answer questions - 10 onty for participants who entered the project during the operating year (from 2b, columns | & 2). The term participant meansSinglesnot in Families andAdults in Famtlies. It doesnot include childrenor caregivers.NOTE: for 7, The total for questions, 8 and 10 below shouldbe the same;respondto eachof thosequestions ali participants. Some of the questions listed throughout the APR will be asking information for hdividuals who are ghronicallY homelg!!.
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6a. Veterans Status.A veteranis anyonewho has ever been on activemilitary duty status How many participants were veterans? I 3 |

6b. Chronically homelessperson. An unaccompanied homelessindividual with a disabling condition who has eitherbeencontinuously homelessfor a year or more OR has had at least four (4) episodes ofhomelessness the past three (3) years. To be considered in chronically homeless personmust have been on the streetsor in an emergency a shelter(i.e. not transitionalhousing)during these stays. For further discussionof the definition of chronic homelessness, Other Key Definitions under the Generallnstructions see above.

How manyparticipants chronically were homeless individuals?

I 0

7.

Ethnicity. How many participants are in the following ethnic categories? Hispanic or Latino Non-Hispanicor Non-Latino

b.

0 3

Explanatory Notes: participant Each should listed only onecategory. totalnumber be in The ofparticipants thistableshould in equal number the ofparticipants in question columns and2. 2b, 1

8.
a.

Race. How manyparticipants in the following racialcategories? are


American Indian/Alaskan Native Asian B lack/African Ameri can Native Hawaiian/Other Pacific Islander

b.
A

0 0 0 2 0 0 0 0 0

White
f. h.
t.

American Indian/Alaskan Native & White Black/African American & White American Indian/Alaskan Native & BlacVAfrican Amencan Other Multi-Racial

s. Asian& White

Explanatory Notes: Each participantshouldbe listed in only one category. A participantwhoserace doesnot correspond categories through i shouldbe to a countedin j, Other Multi Racial. The total number of participantsin this table should equai the number of participantsin question2b, columns 1 and 2. If using HMIS data,you may combine HMIS race response categories generate APR response to the categories.

9a' Special Needs. How many participants have the following? Participants may have more than one. Ifso, count them in all applicablecategories.For eachcondition, also indicatethe number that were chronically homeless. oAlr chronic Mental illness 2 0 b. Alcoholabuse 2 0 Drug abuse 5 0
d.
c.

f.
B,

h.

HIV/AIDS and relateddiseases Develoomental disabilitr Physicaldisability Domestic violence Other (pleasespecify)

0 0
4 I

0 0
E

0 0 0 0

9b. How manyof theparticlpants disabled F are

Explanatory Notes: To determine whichparticipants HLrD'sdefinition "disabled," "Disabling meet of see Condition" underOtherKey Definitions theGeneral in Instructions. 10 HUD- 40118

the places theweekpriorto entering project? (Foreach in sleptin thefollowrng 10. prior Living situation. How manyparticipants 2b, in participants the "A11"columnshouldequalthe numberof participants question in participant, choose piace. Thetotal number-of one (Choose places. one) participants in the following slept homeless how manychronically columns and2). Also,indicate 1
All Chronic

b.
c. d.
E.

Non-housing (street,park, car, bus station,etc.) Emersencv shelter Transitionalhousingfor homelesspersons Psvchiatricfacilitv* Substanceabusetreatment facilitv* Hospital*

3
I

f.

s.
h.
I

Jail/prison*
Domestic violencesituation Livine with r elat iv es / f r r ends Rental housing Other (pleasespecify)

k.

xlf a participant (psychiatric abuse facility,hospital, jail), but wasthere facility,substance treatment or lessthan came froman institution the facility, he/she or shelter beforeentering treatment shouldbe counted eitherthe in 30 daysandwasliving on the street in emergency street shelter or category. appropriate. as

Completequestions11 - 15 for all participants who lgft during the operating year (from 2c, colurnns1 and 2). The term participant means single personsand adults in families. It does not include children or caregivers. The term chronically homeless person means an unaccompaniedhomelessindividual with a disabling condition who has either been continuously of in homeless a year or more OR has had at leastfour (4) episodes homelessness the past three (3) years.To be considered for chronically homelessa person must have been on the streetsor in an emergencyshelter (i.e. not transitional housing) during

these stays. N/A No residents moved out during this period .


11. Amount and Source of Monthly Income at Entry and at Exit. Of thoseparticipantswho left during the operatingyear,how many participants were at each monthly income level and with each source of income? Also, pleaseplace the monthly income level and each source of income for chronically homeless persons in the second column of each chart. The number of participants in Chart A and B should be the same.

AI
A. Monthly Income at Entry No income

Chmnic

..:. i
a.

C. Income SourcesAt Entrv Supplemental Security Income (SSI)

,, : .,tl

AII

Chmnic

-'.

a.

b.
d.

st 50
sl5 - $25 0 s25- s500 $s0 - s1,000
s 1001- 5 0 0 $1 $1501$20 0 0 + $2001

b
d

(SSDI) Social Security Disability Income Social Security PublicAssistance General


Temporary Aid to Needy Families (TANF) StateChildren's Health InsuranceProgram(SCHIP)

f.
g

c.
h.

Benefits Veterans
EmploymentIncome Benefits Unemplorrynent

h.
l.

J.
t.

Health Veterans Care


Medicaid Food Stamps Other (pleasespecify) No FinancialResources

L
m.. n

HUD-401 8 1

. N/A No residents moved out during this period


AII B . Monthly Income
al Exit
i :t,:::l

Chronic
';',:l;11,;, 1: i,:,i;.. :

AII D. Income Sources Exit at


Supplemental SecurityIncome (SSI)
b.

Chmnic

:'

No ncome

b.
d.

s1 50
$1s s250
q7{

Social SecurityDisability Income (SSDI) Social Security

- $50 0

d.

GeneralPublic Assistance TemporaryAid to Needy Families (TANF)

s50 - $1, 0 0 0
i.
6,

$1001- $1 5 0 0 $1501- 0 0 520 + $2001

f.
o

StateChildren's Health InsuranceProgram (SCHIP) VeteransBenefits EmploymentIncome UnemploymentBenefits VeteransHealth Care Medicaid Food Stamps Other (pleasespecify) No FinancialResources

h.

h.
I

J
t-

I m. n.

Explanatory Notes:
Tatrle A: Monthly income at entry refersto the participant'smonthly income on the day he/sheenteredthe program (i.e., on the program entry date or as closeas possibleto that day). You shouldnot report on incomereceivedbeforeenteringthe program or income received during the program stay. Table B: Monthly income at exit refersto the participant'smonthly income on the day he/sheleft the program (i.e., on the program exit date or as close as possibleto that day). You should not report on income receivedduring the programstay. Table C; Income sourcesat entry refersto the participant'ssourcesof income on the day he/sheenteredthe program (i.e., on the program entry date or as closeas possibleto that day). You should not report on sources ofincome receivedbefore enteringthe program or income received during the program stay. Participants with no income at the time of program entry should be reported in category n, No Financial Resources. Table D: Income sources exit refersto the participant'ssourcesof income on the day he/sheleft the program (i.e., on the program exit date at or as close as possibleto that day). You should not report on sourcesofincome receivedduring the program stay. Participants with no income at the time of programexit should be reportedin categoryn, No FinancialResources.

12a' Of those participants who !g[t during the operating year (from 2c, columns 1 and 2), how many were in the pro.iectfor the following lengthsof time? Also, pleaseplacethe length of stayfor chronically homelesspersonswho left during the operatingyear in the second

column. No residentsmoved out during this period. N/A


AII
Less than 1 month
D.

Chronic

d. f.

I to 2 months 3 - 6 months 7 months l2 months l3 months 24 months 25 mon ths - 3v ear s

s.
n.

4y ear s - 5 v e a rs
6 ve ars-Tv ear s 8 vears- 10 vears

Over I 0 vears
Explanatory Notes: Computeeachparticipant'slength ofstay using the participant'sprogTamentry date and programexit date. Ifthe participanthas only one progam exit date during the operating year, calculate length of stay by subtracting the program entry date ffom the program exit date. If the

12

HUD-40118

the length of stay for each program stay (by subtracting the pafiicipant has muitiple program exit dates during the operating year, calculate 'p.ogt"ir add them together to produce a cumulative length of stay' Each iavi and program entry date from the program exit date rot .u.rr number of participantsin the first column ("A11")should participantshould be urso.iai.d"*ith only one length oi stay categoiy. The total equaltt't" number of participantsin question2c, columns 1 and2' the operatingyear (from 2d, columns 1 and 2), how long 12b. Length of Stay in program. For thoseparticipantswho did n.otleaye during homelesspersonsrvho did not Ieaveduring the have they beenin the project? Also, pleaseplace the length of siay for chronically operating year in the second column' All Less than 1 month Chronic

b.
d.

I to 2 months 3 - 6 months
7 months - 12 months

0 0
0

0 0
0

0 12
JI

i3 months 24 months i.
h.
I

2 5mo nths - 3y ear s 4 ve ars- 5Year s 6 ye ars- Ty ear s 8 years - 10 years Over 10 vears

2
6

17

37 0 0

19 0
0

Explanatory Notes: Tocalculate Computeeachparticipant,slengthofstayusingtheparticipant'sprogramentrydateandthelastdayoftheoperatingyear' the lasi day ol the operating year. Each participant should be associatedwith only one length of stay, subtract the prog-ramentry date irom ("A11") should equal the number of participants in question 2d, length of stay category. rf,e totat number of participants in the first column columns1and2. year (from 2c, columns I and2), how many left 13. Reasons for Leaving. of those participants who left the project during the operating participants If a participant left for multiple reasons,include onlythe primary tedson. The total number of for the following reasons? I and2. Also, pleaseplace the primary in the first column (..All") should equal the number of participantsin question2c, columns peisons who !g[ the project during the operating year in the second colunm' reason for chronically 56ms1s55

N/A No residents moved out during this period


AII

Chronic

program beforecompleting Left for a housingopportunity


b. Completed pro$am Non-payment of rent/occupancy charge
u.
A

Non-compliance with Project Criminal activity ldestruction of property / violence Reachedmaximum time allowed in project Needscould not be met bY Project with rules/Persons Disagreement Death Other (pleasespecify) Unknown/disappeared

h.

J.
t.

ta IJ

HUD-40118

I year participants left duringtheoperating (from2c,columns and2), how manyleft for thefollowing who 14. Destination. those Of year persons who left duringtheoperating in thesecond place destination destination? Also,please the ofchronicallyhomeless

column. No residents moved out during this period N/A A'


PERMANENT (a-h)
A

chronic

Rentalhouseor apartment(no subsidy)

b.
c.

PublicHousing
Section8 ShelterPlus Care house or aDartment HOME subsidized

d.

f.
6.

or Other subsidized house aDartment


Homeownership Moved in with family or friends persons Transitionalhousing for homeless Moved in with family or friends Psychiatric hospital

h.

(i-j) TRANSTTTONAL INSTITUTION(k-m)

I
m.

Inpatient alcohol or other drug treatment facility Jail/prison Emergency shelter

EMERGENCY SHELTER(n) oTHER (o-q)


o.
Y'

Other supportive housing Placesnot meant for human habitation (e.g. street) Other (pleasespecify) Unknown

o t'

UNKNOWN

Explanatory Notes: Identify eachparticipant's destination upon leaving the program using the categoriesprovided. The responsecategories combine "destination"(e.9.,rental houseor apartment, public housing,homeownership, etc.) and "tenure" (e.g.,permanent, transitional,etc.). Consider both destination and tenure to determine the most appropriate response,and be sure to look at all ofthe responsecategoriesbefore making a selection. The table below provides a briefdescriptionofeach response category. Enter the number ofparticipants under each destination category in either the first column ofthe table or in both columns ifthe participant is chronicallyhomeless. Only one reasonfor leaving shouldbe recordedper participant.The total number of participantsin the first column ("All") should equal the number of participants in question 2c, columns 1 and 2.

Tenure
Permanent
L

Destination
Rental house or apartment(no subsidv)

Description Participant is moving to an apartment or house without any subsidy. Participantis moving to a public housine unit. Participantwill use a housing choice voucher (formerly known as a Section 8 voucher) to rent a house or apartment.

Public housine 8 Section Shelter PlusCare HOME subsidized house or apartment

u.

Participant movingto a unit funded the Shelter is by PlusCare prosram (e.s.,TBA, SRA,PRA,Section SRO). 8
Participant is moving to a unit with rental assistanceprovided by the HOME Drosram(tenant-based oroiect-based or assistance). Participant is moving to a unit subsidized by some program other than public housing,housing choice voucherprogram (formerly Section 8), ShelterPlus Care-or HOME. Part clpant moving to a unit that he/shehas purchased Participant is moving in with family or friends and expects to live there for 90 days or more. Participantis moving into a unit funded by a transitionalhousing people (e.g.,transitionalhousing funded through programfor homeless the SupportiveHousing Prosram). Participantis moving in with family or fiiends and expectsto live there lessthan 90 davs. Particinantis movins to a osvchiatrichosoital.

f.

Other subsidized house or aDartment

h.

Homeownership Moved in with family or friends Transitional housing for homeless people Moved in with family or fiiends Psvchiatrichospital

Transitional

l.

J. Institution
1.

1A l4

HUD-40118

Emergency Sheiter Other

m n.
o.

Destination Inpatient alcohol or other drug ffeatment facility Jail/Prison Emergencyshelter Other supportivehousing

in+i

Participantis movtng to an lnpatlentalconotor orug trsallllsllrrduurty is Participant moving to a jail or prllen

people. for shelter homeless is Participant movingto an emergency


Participantis moving into supportivehousing that doesnot correspond to any of the permanent housing categories(a-h) and is not transitional housins for homelesspeople (i), such as Section81t housing.* Participant is moving to a place not meant for human habitation, such building. as a car, park, sidewalk,or abandoned to Parlicipantis moving to a place that doesnot correspond any of the above(a-p). categories

p. q.
Unknown r

Placesnot meant for human habitation Other (pleasespecify) Unknown

where about ifyou areunsure be should used category Thisresponse and has is theparticipant movingor ifthe participant disappeared there is. is no wav to find out wherehe/she

*H(JD encouragesprograms to limit the use of the "Other Supportive Housing" APR responsecategory. Programs should report destinations toitousing that are pernxanent or transilional in APR categories (a) through (h) or in categories (i) through (j), respectively. Exits to emergencyshelters should be reported in category @)

15, Supportive Services. Ofthose participantswho !g$ during the operatingyear (from 2, columns 1 and 2), how many receivedthe receivedfor chronically foliowing supportiveservicesduring their time in the project? Also, pleasepiace the supportiveservices homeless participants who left during the operating year in the second column. Participants may have received multiple services and all

in should reporred thetable.. N/A No residents moved out during this period be services
All Outreach b. Casemanagement Life skills (outside of case management) d Alcohol or drug abuseservtces Mental health services f
6.

Chronic

HIV/AIDS-related services Other health care services Education Housing placement

h.

J'
1.

Emolovment assistance Child care Transpoftation

m. n.

Legal Other (please specify)

i5

HUD-40118

Technical year for objectives this operating (fromyourapplication, list 16. OverallprosramGoals.Underobjectives, yourmeasurable the yourprogress meeting objectives. in describe below. UnderProgress, listed ofthe threegoals or APR)for each Submission, year. for objectives thenextoperating the specify measurable Year'sObjectives, UnderNextOperating a. ResidentialStability

Otrjectives: 80% of all participants will remain in housing for one year or move to other permanent housing. Progress: of 99, or 100% of currentresidents 99 who moved in 1+ yearsago are still here. We have had no move outs during this reporting period. objectives:80% of participants will remain in permanenthousing for two or more years or move to other permanent housing. Progress: 100% or 86 of 86 of current residentswho moved in 2+ years ago are still here. We had no move outs during this reporting period. NextOperating Year'sObjectives: Maintain currentobiectives.

b.

Increased Skillsor Income objectives: 70o/o employableparticipants will obtain increasedmarketable skills or income within two years. of

Progress: 93o/o, 80 of the 86 residentsserved during this period who have lived here for at least two years fit this or category. Objectives: 100% of residents will be offered and encouraged receiveeligibility assessments mainstream to for resourcesincluding SSI and VA benefits. 100% of those deemedeligible will be offered assistancein obtaining those resources. Progress: 100% or 100 of the 100 residents, who were servedduring this period have been offered assistance obtaining in resourceleads and eligibility assessments mainstreamresources. for NextOperating Year'sObjectives: Maintain current objectives

c.

Greater Self-determination Objectives: 80% of empioyable participants will be involved in education or training within one year.

Progress:100% of the residents servedduring this period have availed themselvesof our educational services,by taking classeshere or being referred elsewhereor discussingeducationaiand/or vocational opporhrnities with supportive services staff. Objectives:70% of those participants identified as having drug or alcohol abuse/dependence a special need will as attempt or maintain recovery efforts such as individual counseling,relapseprevention groups, in-patient or out patient treatment,or self-help groups during program participation/residency. Progress: 82%o, 78 of 95 residents or with alcohol or drugs as a specialneedusedone or more of the listed help methods. Objectives: 80% of participants that participate in the educationand training service will increasetheir skills in general education and/or in the field, function, or specializationin which educationand,/orfraining was received. Progress: 100% ofresidentsthat usededucation services have increased their skills. Objectives:45% of the participants that increasetheir skills in educationand./orhaining will securepart-time, fuIl time, or volunteer work.

P r ogr es s : 85 o /o ,o r3 5 o f4 l re s i d e n ts u s i n goureducati onal servi cesduri ngtheperi odhadei therw orked, volunt eer ed, or bot

16

HUD-40118

will maintain their housing for at least six months. Objectives:Of the tenantswho develop a rent palment plan, 80o% plan 6 or moremonthsagoarestill here. We havehad no moveouts. who had a payment Progress:100%,or 20 of 20 residents Maintaincurrentobjectives Year'sObjectives: Next Operating

Maintaincurrentobjective. Year's Objectives: Next Operating

17a.S+C 17b.SRO recipients llc. 17. Beds. SHP recipients answer recipients answer answer (SHP-SSO projects do question) not complete this
a. SHP. How many beds were included in the application approved for this project under 'Current Level' and under 'New Effort'? How many of theseNew Effort beds were actually in place at the end of the operatingyeat? New Effort New Effort in Place Current Level q 100 Number of Beds: 0 S+C. How many beds and dwelling units were being assistedwith project funds at the end of the operatingyear? (Include beds for all participants, other family memberb,and care givers.) Numberof Beds: Number of Dwelling Units: c. gyear? at SRO. How many dwelling units were being assisted the end of the operatin (Include units occupied by "in place" non-homelesspersons who qualify for assistance.) Number of Dwelline Units:

b.

T7

HUD-40118

Part II: FinancialInformation


18. Supportive Services, For SupportiveHousine (SHP), this exhibit providesinformation to HLrD on how SHP funding for supportiveservices was spentduring the operating year. Enter the amount of SHP funding spenton thesesupportiveservices. Include HMIS costsunder "Other". For ShelterPlus Care (S+C), this exhibit tracksthe supportiveservices match requirement.Specify the value ofsupportive services from all sources that can be countedas match that all homeless personsreceivedduring the operating year. (S+C grantees shouldkeep documentation file, inciuding source,amount,and type of supportiveservices.) on For Section8 SRO, this exhibit provides information to HtrD on the value of supportiveservicesreceivedby homeless personsduring the operating year.

Supportive Services
Outreach b. Casemanagement Life skills (outside of casemanagement)
d.

Dollars

22,200.59 33,325.13
53,262.01 26,825.04

Alcohol and drug abuseservices Mental health services

32,002.48
468.91 15,215.40 7,825.99 3,718.96 3,864.49

f
6.

AIDS-relatedservices Other health care services Education Housing placement

h.

J
1,

Employment assistance Child care

Transportation
m. Legal

(please Other specify) Nutrition Program


o. TOTAL (Sum of a through n)

1 4 0 ,3 6 . 0 0 1
338,845.00

Cumulative amount of match provided to date for the Shelter Plus Care Program under this grant

18

HUD-40118

Costs, HMIS Activities and Administration 19, Supportive Housing program: Leasing, Supportive Services,Operating year.For expansion operating each charts these mustcomplete HouiingProgram the under Supportive tunding receiving All grantees for and facility,only thepeople expenditures the additional homeless of a pre-existing projects:If SHpgrantfundsarefor theexpansion to used of Documentation resources is not required be or application anygrint amendments. as maybe included, in theoriginal made "*pansion any and by H{.,rD Auditors.Do not include expenditures inspection be but with thisreporr should kepton fil. for possible sutmitted
before the SHP srant was executed Summary of Expenditures. Enter the amounl ofSHP grant funds and cashmatch expendedduring the operatingyear for eachactivity This table shouldadd up both horizontally and verticaliy. The SHP supportiveservicestotal should be the sameas the SHP supportive tron iervlces ln Total Expenditures Cash Match SHP Funds
a. Leasing

b.
c.

SupportiveServices OperatingCosts HMIS Activities Administration Total

338,845.00

84,711.00

423,556.00

d.
t.

8,741.00 347,586.00 84,711.00

8,741.00

432,297.00

of and Note: Payments principal interest on any loan or mortgage may not be shown as an operating expense. Sourcesof Cash Match. Enter the sources of cash identified in the Cash Match column, above, in the following categories. Use additional as sheets, necessary. Amount Grantee/project sponsor cash b, Local government(pleasespecify)

c.

Stategovernment (pleasespecify)

d.

Federal government (please specify) Community DevelopmentBlock Grant (CDBG)

Foundations(pleasespecify)

f.

(pleasespecify) Private cashresources

charge fees / Occupancy


Total

84,711.00
84,711.00

h.

t9

HUD-40118

20. Supportive Housing Program: Acquisition, Rehabilitation, and New Construction in these charts theyearoneAPR mustcomplete or rehabilitation, newconstruction A11grantees received that SHPfundsfor acquisition, of match amount SHPfunds the enough cash at least to equally has will demonstrate HUD thatthegrantee contributed to only. Thisexhibit is to that Documentation matchingfundswereprovided not required be submitted spent acquisition, for rehabilitation, newconstruction. or inspection HUD andAuditors. bv with thisreport should kepton file for possible but be
Summary of Expenditures. Enter the amount of SHP grant funds and cashmatch expendedduring the operatingyear for eachactivity SHP Funds Acquisition b.
c.

Cash Match

TotalExpenditures

Rehabilitation New construction Total

d.

Cash Match. Enter the sourcesof cash identified in the Cash Match column, above,in the following categories. Use additionalsheets, necessary. as

Amount
Grantee/project sponsorcash

b.

Local govemment(pleasespecify)

State government (please specify)

d.

(pleasespecify) Federalgoverrrment Community DevelopmentBlock Grant (CDBG)

Foundations(pleasespecify)

f.

Privatecashresources (pleasespecify)

Occupancy charge/ fees Total

h.

20

HUD-40118

FOR HMIS ACTIWTIES O]YLY


21. For Suppoftive Housins (SHP) - HMIS Activities was spentduring the operating year' Enter This exhibit providesjnformation to HUD on how SHP-HMIS funding for supportiveservices the amount of SHP-HMIS funding spenton theseactivities'

HMIS ActivitiesOnlv
CentralSewer(s) and Printers Computers Personal Networking Securitl Subtotal

Dollurs

,Sq
Software / User Licensing SoftwareInstallation Support and Maintenance Supporting Software Tools Subtotal

Semices
Training by Third Parties / Hostins. Technical Services Programming: Customization Programming: SystemInterface Programming: Data Conversion Security Assessmentand SetuP On-line Corurectivify (Internet Access) Facilitation Disasterand Recovery Subtotal

Personnel
Project Management/ Coordination Data Analysis Programming Technical Assistanceand Training Admrnistrative Support Staff Subtotal HMIS Spuce and OPerations SpaceCosts OperationalCosts Total

21

18 HUD-401

Describe any problems and/or changes implemented during the operating year.

Technical Assistance and Recommendations Based on your experienceduring the last year, arethere any areasin which you need technical advice or assistance? If so, pleasedescribe.

zz

HUD-40118

Report PersonsServedWorksheet - HUD Annual Progress The or of (PPI)onthisformis done withtheknowledge consent theclients. Information Personal Collection theProtected of
PPI is only used for the following purpose: Accurate completion of the Annual ProgressReport (APR) for the Continuum of Care (CoC) HomelessAssistanceProgram in which the client is enrolled. Thisworksheet optional is intended helpyou collect is and to infomration needed complete Annual to the Progress Report. Instructions and Codes follow. Do not submitthis worksheet HUD. to
Relationship Number of Months in Project (calculate) 12a Number of Months in Project Participant did not leave (calculate) 12b New Participant (Y i N )

Non-Homeless (SI Only) ( Y/N ) 4

Persons Served Worksheet (continued) (PPI)on this form is donewith theknowledge consent the clients. The Collectionof theProtected Personal Information or of PPI is only usedfor the following purpose: Accurate completion the AnnualProgress of Reporl(APR)for the Continuum Care(CoC)Homeless of Assistance Program in whichthe clientis enrolled.
Do not submit this worksheet to HUD t\o. Veterans Chronically Ethnicity (YAJ) (code) Status Homeless 6a (Y/N) 7
6b

Race (code) 8

SpecialNeeds (code) 9a

SpecialNeeds (code) 9b

Prior Living Situation 10

Monthly Income At Project Entry lla

Monthly Income At Project Exit 1i b

23

HUD-40118

24

HUD-40118

Persons Served Worksheet (continued) consentof the clients' The coliection of the protected personal Information (PPI) on tlus form is done with the knowledge or PPI is only used for the following purpose: Accurate completion of the Annual progress Report (APR) for the Continuum of Care (CoC) HomelessAssistanceProgram in which the client is enrolled.
Do not submit this worksheet to HUD
Reasonfor Leaving Program (code) 13

Instructions and Codes for Persons Served Worksheet T he u se o f this wo r k s heet is opt ional. I t was de s i g n e d t o he lp yo u co llect inf or m at ion on par t ic ipant s n e e d e d t o co mple te the Annual Pr ogr es s Repor t . I f t he workshe et is up da t ed as par t ic ipant s m ov e in an d m o v e out o f yo ur pro ject , m os t of t he inf or m at ion r eq u i r e d f or co mple tion will be c ont ained in t he wor k s he e t . D o not sub mit th is wor k s heet wit h t he APR. F or pro jects th at s er v e f am ilies , HUD only r equi r e s reporting o n th e n um ber of c hildr en s er v ed, and t h e age an d ge nd er o f t hes e c hildr en. O nly nam e, relation sh ip, da te o f bir t h, and age on t he wor k sh e e t

n e e d t o b e c o m p l e t e d f o r c h i l d r e n . A s s i g n th e a d u l ts a n u m b e r , b u t n o t e a c h f a m i i y m e m b e r . U s e th i s n u m b e r t o t r a n s f e r t o t h e o t h e r p a g e s o f t h e w o r k s h e e t. B e g i n n i n g w i t h n u m b e r 4 , t h e n u m b e r s i n t h e co l u m n s refer to the questions on the APR form. If any q u e s t i o n s a r e a n s w e r e d w i t h " O t h e r , " p l e a s e e n te r th e s p e c i f i c " O t h e r " a n s w e r f o r i n c l u s i o n i n t h e APR . P a r t i c i p a n t N u m b e r . T h i s c o l u m n a l l o w s yo u t o e i t h e r n u m b e r p a r t i c i p a n t s c o n s e c u t i v e l y o r to a s s i g n a c a s e n u m b e r . O n e n u m b e r s h o u l d be assigned to each adult

25

HUD-40118

N ame. Na mes o f p er s ons will not be r epor t ed t o H UD. The use o f n am es is f or y our r ec or d k eepin g conve nie nce. R elatio nship . En ter t he appr opr iat e r elat ions hip . E xample s in clu de : Se1f , Head of hous ehold, Spo u s e , child. E ntry Da te. Ente r dat e par t ic ipant ent er ed t he proje ct. Usu ally this will be t he dat e of ac t ual physical move-in fo r a hous ing pr ojec t . E xit Date . En ter dat e par t ic ipant lef t t he pr oject . U sually this will b e t he dat e t he par t ic ipant physically mo ve d o ut f or a hous ing pr ojec t . Do n o t includ e a p articipa nt who t em por ar ily lef t t he pr o j e c t and is e xp ected to r et ur n in les s t han 90 day s ( e.g . , hosp ital iza tion ). 4. In co me-e ligib le Non- hom eles s in SRO . The S R O pro gra m allo ws as s is t anc e t o unit s oc c upied b y Se ctio n 8 incom e- eligible per s ons r es iding a t t h e SRO p rior to re habilit at ion. For SRO pr ojec ts on ly, in dicate whet her t he par t ic ipant is an income -elig ible , non- hom eles s per s on ( y ) or n o t (N). SHP a nd S+ C pr ojec t s s hould s k ip t his i t e m .

a. Mental illness b. Alcohoi abuse c. Drug abuse d. HIV/AIDS and related diseases e. Developmental disability f. Physical disabiliries g. Domestic violence h. Other (please specify) 9 b . E n t e r t h e n u m b e r o f p a r t i c i p a n t s w i t h a d i sa b i l i ty 1 0 . P r i o r L i v i n g S i t u a t i o n . E n t e r t h e l e t t e r th a t b e st d e s c r i b e s w h e r e t h e p a r t i c i p a n t s l e p t i n th e w e e k prlor to entering the project. Do not double c ou n t . N o n - h o u s i n g ( s t r e e t , p a r k , c a r , b u s s t a t i o n, e tc.) Emergency shelter Transitional housing for homeless persons Psychiatric facility* Substance abuse treatment facility* Ho spital * J a i l / p r i so n * Domestic violence situation Living with relatives/friends Rental housing Other (please specify) xlf a participant came from an institution but w a s t h e r e l e s s t h a n 3 0 d a y s a n d w a s l i v i n g o n th e s t r e e t o r i n a n e m e r g e n c y s h e l t e r b e f o r e e n t e r i n g th e f a c i l i t y , h e / s h e s h o u l d b e c o u n t e d i n e i t h e r th e str e e t or shelter category, as appropriate.

5a. Date o f Birth. Ent er dat e of bir t h inc ludins mo nth , d ay, an d y ear . 5b. Ag e. En ter ag e at ent r y . 5c. Ge nd er, Ente r appr opr iat e let t er f or gender . M -Male F- Fem ale. 6a. Ve tera ns Sta tus . I ndic at e if t he par t ic ipant i s a ve tera n. Ple ase not e: A y et er an is any one w h o ha s e ve r b ee n on ac t iv e m ilit ar y dut y s t at us f o r the Unite d Sta tes . 6 b . Ch ron ica lly h om eles s per s on. I ndic at e t he n umb er of p arti c ipant s t hat ar e c hr onic ally ho mele s s. Eth nicity. Enter appr opr iat e let t er f or et hnic gro up . a . Hispa nic o r L at ino b. Non -Hisp an ic or Non- Lat ino Ra ce . En ter a ppr opr iat e let t er f or r ac e. a. Ame rica n In dian or Alas k an Nat iv e b. Asian c. Bla ck o r Afric an- Am er t c an d . Na tive Hawa iian or O t her Pac if ic I s lander e. Wh ite f. American In dian/ Alas k an Nat iv e & W hit e g. Asian & White h. Bla ck/Africa n Am er ic an & W hit e i. Ame rica n In dian/ Alas k an Nat iv e & B lackiAfrican Am er r c an j. Oth er Multi-R ac ial

Instructi on C odes for P ersonsS erved W orksheet (conti nued r


l l a . G r o s s M o n t h l y I n c o m e a t P r o j e c t B n t r y. E n t e r t h e a m o u n t o f g r o s s m o n t h l y i n c o m e th e p a r t i c i p a n t i s r e c e i v i n g a t e n t r y i n t o t h e p r o j e ct I l b . G r o s s M o n t h l y I n c o m e a t P r o j e c t E x i t . En te r the gross monthly income the participant is receiving when exiting the project. I l c . I n c o m e S o u r c e s R e c e i v e d a t P r o j e c t E ntr y. E n t e r a i l t y p e s o f a s s i s t a n c e t h e p a r t i c i p an t i s receiving at entry to the project. a. Supplemental Security Income (SSI) b . S o c i a l S e c u r i t y D i s a b i l i t y I n s u r a n c e ( S SD I) c. Social Security d. General Public Assistance e. Temporary Aid Needy Families (TANF) f. StateChildren's Health InsuranceProgram(SCHIP) g. Veterans benefits h. Employment income i. Unemployment benefits j. Veterans Health Care k. Medicaid l. Food Stamps m. Other (please specify) n. No Financial Resources

9 a Sp ecial Nee ds. Ent er t he let t er ( s ) f or t he


cate go ry(ie s) that des c r ibe t he par t ic ipant ' s disa bility(ies). ( You m ay double c ount ) .

26

HUD-40118

l ld.In co me Sou rce s Rec eiv ed at Pr ojec t Ex it . En ter all type s of inc om e t he par t ic ipant is re ce ivin g a t pr ojec t ex it . ( Us e c odes as in 1 1 c . ) l2a Le ng th in Stay in Pr ogr am . Caic ulat ed it e m . (Se e Entry Date and Ex it Dat e abov e. ) 12b. L en gth of Sta y in Pr ogr am . ( Par t ic ipant d i d n ot lea ve d urin g t he oper at ing y ear . How lo n g h ave th ey b ee n in t he pr ojec t ?) 13. Re ason fo r L ea v ing Pr ojec t . Ent er t he pr im a r y re ason why the par t ic ipant lef t t he pr ojec t . (Co mple te on ly f or par t ic ipant s who lef t t he p roje ct a nd a re not ex pec t ed t o r et ur n wit hin 9 0 d a ys. a . Le ft fo r a ho us ing oppor t unit y bef or e comp letin g the pr ogr am b . Co mple ted p r ogr am c. No n-p aymen t of r ent / oc c upanc y c har ge d. Non -co mplia nc e wit h pr ojec t e . Crimina l act iv it y / des t r uc t ion of pr oper t y / vi o l en ce f. Re ache d max im um t im e allowed in pr ojec t g. Ne ed s co uld not be m et by pr ojec t h . Disa gre eme nt wit h r ules / per s ons i. De ath j. Oth er (p lea s e s pec if y ) k. Unkno wn/d is appear ed

15. Supportive Services. Enter all types of s u p p o r t t v e s e r v i c e s t h e p a r t i c i p a n t r e c e i ve d d u r i n g the time in the project. a. Outreach b. Case management c . L i f e s k i l l s ( o u t s i d e o f c a s e m a n a g e m e n t) d. Alcohol or drug abuse services e. Menral health services f. HIV/AIDS-related services g. Other health care servrces h. Education i. Housing placement j. Employment assistance k. Child care l. Transportation m. Legal n. Other (pleasespecify)

14. De stin atio n. E nt er t he des t inat ion of t hos e lea vin g the p rojec t . Pe rman en t: a . Ren tal hous e or apar t m ent ( no s ubs idy ) b . Pu blic H ous ing c. Section 8 d . Sh elte r Plus Car e e . HOME s ubs idiz ed hous e or apar t m en t f. Oth er su bs idiz ed hous e or apar t m ent g . Home ow ner s hip h . Mo ve d in wit h f am ily or f r iends T ra nsition al: i. Tra nsitional hous ing f or hom eles s per s o n s j. Moved in wit h f am ily or f r iends Institutio n: k. Psych iatr ic hos pit al. l. Inp atie nt alc ohol or dr ug t r eat m ent f ac i l i t y m. Ja il/prison Emerg en cy: n. Eme rge nc y s helt er Othe r: o. Othe r sr ippor t iv e hous ing. p. Places n ot m eant f or hum an habit at ion (e.9 ., stre et ) q. Othe r (pleas e s pec if y ) Un kn own : r. Un kn ow n

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HUD-40118

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