U. S.

Department Housing of and Urban Development Officeof Comrnunity planning andDevelopment

OMB Approval 250G0145 No. (exp.t 1/30/2009)

GOPY

Annual ProgressReport (ApR)

for SupportiveHousingprogram plus Care Shelter
and Section8 Moderate Rehabilitation for Single Room Occupancy Dwetlings (SRO) program

H U D- 401i8

instructions, public reportingburdel for this collection information estimated average hours respollse, the per including time for reviewing to 33 is of the may of and gathering maintaining dataneeded, completing reviewing collection information.This agency and searching existing and the data sources, displays vatidOMB coutrol a number. that unless collecbn notconduct sponsor, a person not required respond a collection to to, ofinformation or and is

General Instructions Purpose, The Annuai Progress Report (APR) is a reportingtool that HUD usesto track program progressand accomplishments inform the Deparlment'scompetitiveprocess homeless assistance funding. and for Filing Requirements. Recipients F{UD's homeless of assistancegrants must sutrmit 2 APR'S to HUD within 90 daysafter the end of,each orrerating year. One copy of the report must be submittedto theCorrmunity Pianning and Dwelopment (CPD) Division Director in the local HUD Field Office responsible managingthe grant. The other copy must be.subrnitted for to HUD Headquarlers, Departmentof Housing and Urban Development,Attn: APR Data Editor, Ptaom7262,451 7" Street, SW, Washington,DC. 20410. Failure to submit an APR will delay receiving grant funds and may result in a determination of lack of capacityfor future funding. An APR must be submittedfor eachoperatingyear in which HUD funding is provided. Grantees that receivedSHP funding for new construction, acquisition,or rehabilitationare required to operatetheir facilities for 20 years. They must submit an APR 90 days after the end of the first operatingyear andevery year throughoutthe 20 years. A separate report must be submittedfor each HUD grant received. For SheltelPlus Care(S+C),a separate APR must be submittedfor eachS+C component. For thosegrantees receiving an extension,a separate repofi covering that period mustbesubmitted(seeExtensionbelow). Recordkeeping. Grantees must collect and maintain information on eachparticipantin order to complete an APR. Optional workslreets attached,The worksheetsmay be usedto record information manually or to designacomputerizedsystemto are storeand tabulatethe information. The worksheetsshould not be submittedto HUD with the APR. Organization of the Report. The APR is organizedin the following manner: Part I: Project Progress. This portion of the report describes progressin moving homelesspersonsto selfsufficiency, the documenting and accountingfor beds/units. servicesreceived,listing project goa1s, receiving funding undel SHP, S+C, Part II: Financial Information. This portion of the repoft is completedby all grantees and SRO. number every page sequentially. Mark any questions that do Final Assembly of Report. After the entire report is assembled, not apply to your program lvith "N/A" for not applicable. (See SpecialInstructionsforSSO Projectsbelow.) type is defined below, Note that a client's client/household Definitions of Client,lHouseholdTypes. Each client/household type shouldbe basedon the client's age and/or householdcompositionat theprogram entry date closestto the start ofthe operating year. Families - A family is a householdcomposedof two or more relatedpersons,at leastone ofwho is a child accompanied by an adult or ajuvenile parent. by Singles not in Families - Persons not accompanied children, including pregnantwomen not accompanied other by youth present youth, are singlesnot in families. When two adultsor two unaccornpanied childlen and unaccompanied togetherfor services, eachpersonshould be countedin singlesnot in families.. Clients' householdstatusshouldbe determinedbasedon their householdcompositionat the program entry date closestto the starl of the operatingyear. This meansthat pregnantwomen expectedto give birth during their program stay should stiil be counted as singlesnot in families. Adults in F amilies - Within a family, an adult is any person 18 years of age or older. For the purposesof APR reporting, the determinationof whether a person is an adult in family should be made basedon theirageand householdcomposition at the program entry date closestto the startofthe operatingyear. by Children in Families - Children in Famiiies are defined as children under the age of 18 accompanied one or more a dult s ( par ent , r e l a ti v e o rg u a rd i a n ), i l d re n i n fami l i esal soi ncl udebothaj uveni l eparentandtheparent' schild( r en) . Ch For the purposesof APR reporting, the determinationof whether a personis achild in family should be madebasedon their age and householdcornpositionat the programentry date ciosestto the stalt of the operatingyear. For example, ) HUD-401 I8

during clientswho are lessthan tg years of age on the first day ofthe operatingyear or at program enul (ifthey entered year) should be countedas children evenifthqz tum iS during the courseofthe operatingyear. the operating Persons in Families - Personsin families includesadultsin families and children in famiiies.

tems are applieddifferently Other Key Definitions. The foilowing tems are used in the APR. As indicated,in some cases, dependingon whetherthe funding is from SHP, S+C, or SRO. Chronically homelessperson - HUD definesa chronicallyhomeiess personas"an unaccompanied homeless individual with a disablingcondition who has either been continuouslyhomelessfor a year or moreoR has had at leastfour (4) episodesof homelessness the past three (3) years." To be considered in chronically homelesg personmust have been on a the streetsor in an emergencyshelter(i.e, not in transitionalhousing) during thesestays. HUD's definition of a chlonically homelesspersonisbasedon the following components . homelessindividual has the samecharacteristics Unaccompanied homelessindividual: an unaccompanied above), of a Single not in a Family (described r under disablingcondition (below) to detenninewhethera client is Disabling condition: seethe instructions disabled. year. Did not leave the program - This term refersto clientswho were in the program on the last day of the operating Disabling condition - HUD defines a disabling conditionas: (l) A disability as defined in Section223 of the Social Security Act; (2) a physicai, mental, or emotiond impairmentwhich is (a) expectedto be of longcontinuedand indeflrnite and (c) of such a naturethat suchability duration,(b) substantiallyimpedesan individual's ability to live independently, disability as defined in section 102 of the could be improved by more suitablehousing conditions;B) a developmental of DevelopmentalDisabilities Assistanceand Bill of RightsAct; (4) the disease acquiredimmunodeficiencysyndromeor any conditionsarising frorn the etiological agencyfor acquiredimmunodefciencysyndrome;or (5) a diagnosable substance abusedisorder. program, Entered the program - Enteredthe program refersto the first day a client receivesservices,For a residential this datemay represent day the this datewould representthe firstday of residencein the program's housing For services, of program enrollment,the day a servicewas provided,or the first date of a period of continuousprticipation in a service (e.g., daily, weekly, or monthly). For For S+C and SRO programs,the program entry dateis the datethatthe participantstartsto receiverental assistance. and for provided prior to this point are recognized necessary outreach./enrollment are eligible to count as as S+C, services match. and received an extensionof their grantterm from that requested An Extension APR appliesto SHP and S+C grantees the the HllD field office. The only differencebetweenan APR for the extensionperiod and the regular APR (besides should circle "yes" to indicatethe APR is for an extenslon amount of time covered)is the signaturepage. Grantees period and circle the operatingyear for which the reportis an extension.For example, if the granteeis extendingyear 3, the granteeshould submit an APR as usual for year 3 and submit anotherAPR for the extensionperiod, indicatingthe page. secondis an extensionand also circiing year 3 on the signature Grantee meansa direct recipient of the HUD award. Left the program - Left the program refersto the last day a client receivesservices.For a residentialprogram,this date the would represent last day of residencein the program'shousing. For services,the exit datemay represent last day the service. If a client leavesthe program temporarily(e.g., a servicewas provided or the last date of a period of continuous for a hospitalization) but is expectedto return within 30 days,do not count that client as having 1eftthe program. and For S+C pxograms, program exit daterefersto the datethe pafiicipant stopsreceiving rental assistance is not the person housing within 90 days,the housing. If the participantreturnsto S+C assisted expectedto retum to S+C assisted ihe program. f the personretums to S+C assisted housing after 90 days,that shouid not be consideredas exiting from person is considereda new parlicipant, The worksheetis designedto capturethis information.
HU D - 4 0 1 1 8

by reoeived participantsin the S+C troject which, in the aggregate' Match for S+C is the value of supportiveservices provided over the life of the project' For SHP' matchis cash must at leastequalthe value of the S+C rental assistance new construction,operatiolsand supporliveservices rehabilitation, usedto provide the grantee'sportion of acquisition, expenses. Operating year - For SHP programs,the first operatingyear beginsafter developmentactivitiesfor acquisition, rehabilitation, and new constructionare complete,after a copy of the Certificateof Occupancyis sentto the local HUD rehabilitation,ol'new office, and when the first participantis accepted into the project. For projectswithout acquisition, construction, operatingstart date beginswhen the granteeaccepts first participant.For dedicated the the HMIS projects, the operatingyear begins when any eligible cost includedin the approvedproject budget is incuned. For S+C (SRA, PRA and TRA components), first operatingyear beginson the dateHUD signsthe grant agreement.For S+C/SRO the and for Sec.8 SRO, the first operatingyear beginswith the effective date of the Housing Assistance (HAP) Payments Contract. To determine which operatingyear to circle on the APR cover page,begin counting from the initial grant operatingstarl dateand inciuderenewalgrants. For example,a projectreceiving an initial grant for three yearsand a renewalgrant for two yearswould circle years 1, 2, and 3 respectively the AFR cover sheetfor the initial grant and would circle 4 and 5 on respectively the renewal grant. For any future renewalgrants,the granteewould begin by circling 6 on the APR cover for sheet. Participants - The term participantrefersto Singlesnot in Familiesand Adults in Families as definedabove. Participant doesnot include children or caregiverswho live with the adultsassisted. Project Sponsor meansthe organizationresponsible carrying out the daily operationof the project,if the for organization is an entity other than the grantee.

shouldcomplete questions, all Srrecial Instructions for Supportive Service Only (SSO) Programs. SSO grantees using estimtes, uniessa wriften agreement has been reachedwith the field office concemingwhich questionscan be answered or in rare instances, skipped. Below is an exampleof how information could be derived in a large, singleserviceSSO project: housingthe participants, The A grantee/sponsor staff member could be assigned collect information from the organizations to staff person would contact these individual organizationsto request information regarding thepersonsin that facility that use the service.For participantsliving on the street,the grantee/project sponsormayprovide estimates. or information could be collectedfor each participantor for participanisreceiving servicesat a point-in-time. If estimates point-in-time countsare used,the method usedmust be described the APR and the documentation kept on file. in grants,grantees operatingSSOprojectsare expected to As with all projectsfunded underHUD's homelessness assistance completeall APR questions that are applicableto them. Note that all projectshave been awardedfunds as a result of their skills and respondingto the program goals of assistinghanelesspersonsobtain/remainin permanenthousing and increase income. The APR documentstheir progressin meetingthesegoals. that can b answered using may sign a written agreementconceming questions In some circumstances field offices and grantees estimates, in rare instances, below for reporting on specialtypesof projects,suchas or skipped. Seethe specialinstructions outreachonly projects,projects providing services children oniy, and transpofiation,medical,dental,atd other single,shortto duration serviceprojects. transitionalhousingprograms, following emergencyshelters, SSO programsare a third priority for local HMIS implementation, outreachprograms,and permanentsupportivehousingprograms. Once SSO programsare included in the HMIS, SSO grantees that arenot yet participatingin HMIS will need will be able to answerall APR questionsusing their HMIS data. SSO grantees above, to collect datato answerthe APR questionsusing the specialinstructionsprovided are Outreach Only Projects. Projectswhich are solely devotedto streetoutreachand connectionto housingand services not requiredto track participantsbeyond their contactwith personson the street. It is sufficient for theseprojectsto enter
HU D - 4 0 1 1 8

giventhat for questions1-l3 and 17). Estimates questions5-9 are allowed, 1 inforrnation questions 10(skipping on 1questions. participants be reluctant answer personal may to Answeling questions demonstrate thegrantee serving appropriate providing the that numberof people, will is the basic persons beingserved, demographic demonsh atingthathomeless are dernonstrating types information Congress, for tl'le of liousilg participants connected andthetype ofservices to, theyarereceiving. are flotline Projects. Hotlineservices similarto outreachonly projects, contact are grantee participant often but befween and is of very shortduration people enterandleave program the nearly It simultaneously. is sufficient these for projects answer to questions (skipping 10,and14-19 (skipping 1-5 4), l7). Projects Providing To Services Children Only.Projectsthat providechild care,after schoolcare,counseling children, for etc.makean importantcontribution towardmovinga familyout of homelessness. While the main focusof the projectis providingservices thechildren, is the adultswho are reported in questions to it on 6-16of the APR. Like all other projects, this type is alsotargeted towardgettingthe families and increasing families'incomes. into housing the Grantees skip question all otherquestions may (except should answered 9; be 17). Transportation, Medical, Dental, and Other Single,Short-Duration Serwice Projects. Some grantees provide a singleservice fairly shotlduration of focused ONLY indirectly assisting honeless persons obtain/remain permanent on to in housing andincrease projects enterinformaion questions and14theirskillsandincornes. is sufficient these It for to on l-10 l9 (question maybe skipped). 17 However, with transportation it to services, is unreasonable think thatsomeone wouldhave to give theirage,race, ethniciry a busdriverto geta ride a few blocks to and provide narrative, For these services, a whichgivesthenumber ridesgivenduringthe operating year', provides of and estimates on the above statistics based thepopulation utilizes service. on that the Speeial Instructio4s F pr Spfe flaven (SH) Proiects. Grantees should repofion all participants served during the year, Note: this is a change operating frornprior instructions wheregrantees wereinstructed reporton thefirst25 to participants served. Srreciai insrruciions iur iiuureiess I'IanaEenieni Information S','stem{IIMIS) Froiects- H\4!Sgr'?.'rteis shouldfilI out the coversheet theAPR PartII Financiai Aciiviiiesseciion. of information. theHNCIS anci

H U D- 401t 8

THIS PAGE - TO BE COMPLETEDBYALL GRANTEES

Grantee:

CityandCounty SanFrancisco, Department Human of of Services

Project Sponsor: Housing Services Affiliate of the Bernal Heights NeighborhoodCenter
OperatingYear: (Circletheoperating yearbeingreported or)

HUD Grantor Project Number: cAO 1C501 I 044

ProjectName:

HazelBetsey Apts.- 1 Bedrooms

ReportingPeriod: (month/day/year)

[lt Jz trl X+ trs no Zt ns ns nro [tt n tz f]rsn r +l rs l ro l rz l re D rsl z b

Indicate extension: fl yes X No if Indicate renewal: if I Yes n No Previous Grant Numbers thisoroiect: for

trom:7/1/06

to6/30/07

cAO1 c401 049 cAo1 c3 0 1042 cA39C9501 50

Check the componentfor the program on which you are reporting.

SupportiveHousing Program (SHP) Ll ! tr r rans[lonatHouslng Permanent Housing for Homeless Persons with Disabilities Safe Haven

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

Section Moderate 8 Rehabilitation n Single RoomOccupancy (Sec. SRO) 8

f] Innovative SupportiveHousing [-l . SupportiveServicesOnly fl FIL{IS

Summary of the project: (One or two sentences with a descriptionof population,number servedand accomplishments this operating year)

year, this projectprovided to four unitsof permanent Duringthis operating up housingto homeless families.All ihe families camefrom eitherthe streeisor emergency shelters and had one or morespecialneedsrelated mental to health, substance use,and/orHIV/AIDS.
Name & Title of the Personu,ho can answerquestionsabout this report: Phone: (include areacode)

Sumi lmamoto, Asset Manager,HousingServices Affiliate the BHNC (415) 206-2140 of

Address: Fax Number: (rncludeareacode)

HousingServices Affiliate the BernalHeightsNeighborhood of Center 515 Cortland Ave. San Francisco, CA 94110 E-mail Address simamoto@bh org nc.

(415) 648-07e3

I hereby certify that all the information stated herein is true and accurate.
Warning: HUD will prosecute false claims and statements.Conviction may ilpenalties. 18 U.S.C. (

1 0 1 0, 012;31 U. S . C3 7 2 9 3 8 0 2 1 . .
Name & Title of Authorized GranteeOfficial S i gnal

Adviento. Shelter PlusCareProsrarn Grants & Anal

Name and Title of Authorized Proiect SponsorOfficial

o{N,

Justine Lauderback-Strebler, of Director Finance Admin. and

q2sl*
HUD-401 I8

(EXCEPT HMIS) PARTI, TOBE COMPLETED ALL GRANTEES BY

SSO GRANTEES, PLEASE SEESPECIALINSTRUCTIONS PAGE3 OF THEAPR ON Part I: Project Progress
l Projected Level of Persous to be served at a given point in time. (This information comesfrom themost recentCoC
lcatlon. Number of Singles Not irr Families
J

Proiected Level
a.

Number of Adultsin Families

A

Number of Children in Families

Number of Families

Persons be servedat a given point in time to

2.

PersonsServed during the operating year.

Number of SinglesNot in Fami l i es

Number of Adultsin Families

Number of Children in Families

+

Numberof Families

Number on the fir'stday of the operatingyear b. c, d. Nurnber entering program during the operaiing year Number who left the program during the operatingyear

0 0 0 0

0
0
J

0 0
A

year Number the program thelastdayof theoperating in on (a + b- c ) : d

Explanatory notes: SeeDefinitions of Client/Household Types in the GeneralInstructionsabove to determinewhich clients should be counted as Singles Not in Families,Adults in Families,and Children in Families. Note that this table doesnot accountfor changesin client/household type thatmay occur during the courseof the operatingyear. Instead,eachclient should be assigned singleclient/household a type basedon the client's age and/ol householdcompositionat the program entry date closestto the start ofthe operatingyear. ln this way, eachclient is counted only once in the table. to Use the following graphic and explanations determinewho should be counted in rows a-d:
i i .___"]-__-.-.-. i Clienl program firstdayof in on year, leftduringthe operating in count 2a and2c. Vsa(: Clienl program firslday on in yearand last of opBrrting year:counl dayoioperatang i n 2a and2d. H
.!....

Ciienl enlerBd len and prcgram dunngoparatrng yearicounlin 2b and2c. program during Clienl onterod yearandstillin opsrating program lasl dayofysar: on counlin 2b and2d.

Client entered and lefl program before starl of opsratingyesri do nol count in queEtion 2.

Finl day oftha operalingyear

Lastday ofthe year operating

a,

Number on the first day ofthe operating year:This row includesall clients who enteredthe program before the first day ofthe operatingyear and did not leavethe plogram until afterthe first day ofthe operatingyear. Number entering the program during the operating year: This row includesall clients who enteredthe program on or afterthe first day of the operatingyear, up to and including ihe last day of the operatingyear. Fol clients with multiple program enhy dates, usethe entry date closestt0 the stalt of the operatingyear. Do not count the client more than once even if hdshe enteredthe programmore than once during the operatingyear. Number who left during the operating year: This row includesall clients who left the program on or after the first day of the opelatingyear, up to and including the last day ofthe operatingyear. For clients with multiple program exit dates,usethe exit date j HUD-401 I8

b.

c.

during exited program the morethanonce year.Do not counttheclientmorethanonceevenif he/she closest the endof theoperating to year. theoperating d. Numberin the programon thelastday oftheoperating year: Thisrow includes clients all whowerein theploglam of thefirst as dayofthe operating or who entered year year duringtheopefating andwhodid not leave year,Thenumber duringtheoperating of clients familiesin theprogram thelastdayofthe operating is calculated or on year based theresonses rows2a through For on to 2c. each column,addthenumber clients families row 2a to thenumber clients familiesin row 2b andsubtract number of or in of or the of clients families row 2c. Therefore, : 2a+ 2b -2c. or in 2d

3.

Project Capacity.
Number of Singles in Not Families Numbcr on the lastday (from 2d, columnst and 4) Nutnber of Adultsin Families Number of Children in Families Number of Families

0 0
0% 100 %

b. c.

proposed application Number (fi'omla, columns and4) in I Capacity Rate(divideaby b) = %

Explanatory Notes: Row b refers the mostrecent to CoCapplication whichtheprogram repot'ting. for is

4.

Non-homelesspersons. This questionis to be completedfor Section8 SRO projects. Not Applicable

How many incomoeligible non-homeless personswere housedby the SRO program during the operatingyear?

5.

Age and Gender, Of thosewho entered the project during the operatingyear, how many people are in the following age and gendercategories?
SinglePcrsons(from 2b. column L Age Male

Fernale

b.
d.

62 andover 51-61 3l -50 I 8-30

17 and under

Personsin Families(from 2b. columns2 & 3)

f.
h

62 and over

51- 6l 31 - 50

18-30
k. l.
m.

13-17 6-12 l -5 UnderI

Explanatory Notes: This question refers only to Singles in Families Persons Families not and in who entered proglamduringtheoperating year'. the Onlyclients who meetthese criteria be counted thistable.The totalnumber can in ofclientsreported underSinglePersons should equal the be to number reported question columnl. Thetotalnumber clients in 2b, of reported under Persons Families in should equal thesumof be to colunrns and3 in question 2 2b. Answer questions - l0 only for participants who entgred the project during the operatingyear (from 2b, columns| & 2). 6 The term participant meansSinglesnot in Familiesand Adults in Families, It doesnot include children or caregivers.NOTE: The total for questions,7,8 and 10 below should be the same;respondto eachof those questionsfor all participants.Someof the questionsiisted throughoutthe APR will be asking information for individualswho aregblonically homeless.

H UD - 4 0 1 t 8

6a. Veterans Status. A veteran is anyone who has ever been on active rnilitary duty status.

rnany parrrcrpanls velerans, How were

lill

6b. Chronica[y homeless person An unaccompanied homeless individualwith a disablingconditionwho haseitherbeencontinuously homeless a year or more OR has had at leastfour (4) episodes for ofhomelessness the past three (3) years. To be considered in chlonically homelessa person nrust have been on the streetsor in an emergencyshelter'(i.e. tl'ansitional not housing)during thesestays. For furthel discussionof the definition of chronic homelessness, e Other Key Definitions under the GeneralInstructions se above.

Howmanyparticipants chronically were homeless individuals?

| ?

7. a.

Ethnicity. How many pa(icipants are in the following ethnic categories? Hispanic ol Latino Non-Hispanicor Non-Latino

b.

0 0

Explanatory Notes: Each participantshould be listed in only one categoly. The total number of participantsin this table should equalthe number of participants , in question columnsI and2. 2b,

8.

Race. How many participantsale in the following racial categories? American Indian/AlaskanNative Asian Black/African American Native Hawaiian/OtherPacific Islander

White
f. h. i. American Indian/AlaskanNative & White

Asian& White
Black/Aflican American & White

American Indian/Alaskan Native& Black/African American OtherMulti-Racial

E xplana tory No tes: Each participantshould be listed in only one category. A participantwhose race does not collespondto categories through i should be a countedin j, Other Multi Racial. The total number of participantsin this table should equal the number of participants question2b, in colunrns 1 and 2. If using HMIS data,you may combine HMIS raceresponse categor to generate APR response ies the categories.

9a. Special Needs. How rnany participantshave the following? Participantsmay have more than one. ifso, count them in all applicable categories.For eachcondition, also indicate the number that wel'echronically homeless. All Chronic a. Mentalillness b. Alcohol abuse

Drus abuse
d e f.
h.

HIV/AIDS and relareddiseases

Develonmental disabiliW
Physicaldisabilitv Dornesticviolence Other (please specifu)

9b. How manyof theparticipants disabled? are

t:

Explanatory Notes: To determine whichparticipants meetHUD's definition "disabled," "Disabling of see Condition" underOtherKeyDefinitions theGeneral in Instructions. HUD- 401r 8

places theweekpriol to entering project?(Foreach the 10. Prior Living Situation.How manyparticipants in thefollowing in slept participant, in choose place.Thetotalnumber parlicipants the"All" column equal number participants question the of 2b, one of in should columns and2). Also,indicate 1 participants in thefollowingplaces,(Choose how manychronicallyhomeless slept one)
All
a.

Chronic

b. d.

(street, park,car, bus station, ) Non-housing etc. Emergencyshelter

persons Transitional housing homeless fol

Psvchiatricfacilitv* Substance abuse treatment I itv* faci Hospital* Jail/olison* Domestic violence situation Livine with relatives/friends Rental housing Other (oleasesoecifv)

t
h
I

1.

*If a participantcamefrom an institution(psychiatricfacility, substance abusetreatmentfacilify, hospital, or jai|, but was there lessthan 30 days and was living on the streetol in emergencyshelterbeforeenteringthe treatmentfacility, he/sheshould be countedin eitherthe street or shelter category, as appropriate.

questionsI - 15 for all participantswho left duringthe operating year (from 2c, columns and2). Tlieterm 1 I Complete parlicipant means persons adults families, does include children caregivers. termchronically or The singie and in It not person homeless condition who haseither mearls unaccompanied an homeless individual with a disabling beencontinuouly homeless a yearor moreOR hashadat least for in To four (4) episodes homelessnessthepastthree(3) years. be considered of (i.e,not transitional housing) durig chronically homeless person a musthavebeen the streets in an emergency shelter on or these stays.
year,how many who left during the operating 11. Amount and Sourceof Monthly Income at Entry and at Exit, Of thoseparticipants participants were at eachmonthly income level and with eachsourceof income? Also, pleaseplace the monlhly income level and each sourceof incomefor chronically homelesspersonsin the secondcolumn of eachchart. The number of participantsin Chart A and B should be the same.

Arl
A. Monthly Income at Entrv No income b.

Chronic

All

Chronic

At Sources Entry C. Income

a.
h

$l- 150

(SSI) Income Security Supplemental Disability Income(SSDI) Social Security SocialSecurity PublicAssistance General (TANF) Aid Temporary to NeedyFamilies (SCHIP) Insurance Program Children's Health State
Veterans Benefits Employment Income UnemploymentBenefits

$15r $2s0 d.

$251$500 $501 $1, 00 0 -

f.
g

s1001$1500 $150r$2000
+ $2001

t
g

h.

h.

j
l.

Veterans Health Care Medicaid Food Stamps Other (pleasespecify) No Financial Resources

l.
m..
11,

i0

HUD,40t t8

AU
B. MonthlyIncome at Exit No income
b,

Chronic

AI Sources Exit at D. Income

a,

Chronic

$l- 150

b.
d

(SSI) Security Incorne Supplernental (SSDI) Income Security Disabiliry Social Social Security PublicAssistance General (TANF) Aid Temporary to NeedyFamilies
StateChildren's Health InsuranceProgram (SCHIP)

$151 $2s0 d.

1$25 $500

f.
6.

$501 $1,000 t;1001$1500

f.
g

$r 5 0 r$ 2 0 00 + $2001

Benefits Veterans
EmploymentIncome

h.

h.

Benefits Unemployrnent
J
L

FlealthCare Veterans Medicaid

L
ln

FoodStamps (please specify) Other

No FinancialResources

n.

Explanatoty Notes: (i.e.,on theprogrrn the on entered program income the dayhe/she to monthly Table A: Monthlyincome entryrefers the participant's at entering program income the or received received before not on entrydatoor asclose possible thatday). You should report income as to during program lhe stay. left exit monthlyincome thedayhe/she theploglam(i.e.,on theplogram date on to Table B: Monthlyincome exit refers the parlicipant's at duringthe program stay. received to or ascloseaspossible thatday). You shouldnot repofton income (i.e.,on theprogram the on enteled program sources income the dayhe/she to of sources entl'yrefers theparticipant's Table C: Income at received before entering program income or of the not on to entrydateor asclose possible thatday). You should report sources income as be in n, entryshould reported category No Financial at with stay,Participants no income thetime of prograrn received duringtheprogram Resources. (i.e., theprogram date left on exit on sources income thedayheishe theprogram of at to Table D: Income soul'ces exit refers theparticipant's duringtheprogl'am stay.Participants no with received of as ol asclose possible thatday). You shouldnot reporton sources income to Resources. n, in exit shouldbe repofted category No Financial income thetimeof program at for 1 year participants !e:S duringthe operating (from2c,columns nd 2), how manywereintheproject the following rvho 12a.Of those year persons lgft duringtheoperating in thesecond who homeless place lengthof stayfol chronically the Ielgthsof tirne?Also, please column. All
a.

C hroni c

b
c

f.
o

LessthanI month I to 2 months 3 - 6 months 7 months 12 months 13months 24 months 25m ont hs -3 v e a rs 4y ear s - 5y e a rs
6vea rs-Tve als 8 vears- 10 veals

h.

OverI 0 years
Explanatory Notes: Ia e. C ompute ea ch pa rticip ant ' s lengt hof s t ay us ingt hepar t ici p a n t 's p l o g r a m e n t r y d a t e a n d p r o g r a m e x i t d f tth e p a t i c i p a n t h a s o n l yo n e ploglam exit dateduring the operating year,calculatelength of stayby subtractingthe plogLamentry date from the programexit date. If the participant has rnultiple program exit datesduring the opelatingyear,calculatethelength ofstay for each programstay(by subtlactingthe program entry date frorn the program exit date for:eachprogramstay)and add thenr togetherto produce a cumulativelength of stay. Each

il

H U D .4 OI I8

("All") should in of participants thefirst column The of with be participanr should associared only onelength staycategory. totalnumber I 2c, in of Lquat number participants question columns and2' itte 1 year duringtheoperating (from2d, columns and2), howlong who participants did not leave 12b. Lengthof Stayin program. For those during the persons who did not leave homdess of hawe rtrevheenin the project?Also, please place length itay for chronically the column. year operating in thesecond All
b.
/.1

C hroni c

LessthanI month I to 2 months 3 - 6 months

7 months- 12 rnonths

e. f
g

13 months 24 months 25 mon ths-3y ear s

4v ear s - 5v e a rs 6v ear s - T ve a rs
8 vears- l0 veals

l.

Overi0 vears

Notes: Explanatory year'.To calculate program entrydateandthelastdayofthe operating participalt's lengthofstay usingtheparlicipant's each Compute with shouldbe associated only one year.Eachparticipani entry datef.om iite lasi day of the operating lengthof stay,iubtractthe program 2d, in of the ("All") should equal number participants question in number participants thi first column of The toltal of tengttr staycategory. 1 columns and2. I year(from2c,columns and2), howmanyleft duringtheopelating parlicipants lgft theproject who for 13. Reasons Leaving.Of those of clutleonlv theprimaryredson,The totalnumber participants left If for thefollowingreasons? a participant for multipl- reasons,la place primary the I question columns and2. Also,please 2c, in of (..All") shouid equalthenumber participants in thefirst column column. year duringtheoperating in the second left personswho theproject for r.eason chronicallyhomeless
All a. Chronic

b.
d.

progt'am Left for a housingopportunitybeforecompleting program Completed

Non-payment of rent/occupancy charge Non-compliancewith project

/ of Criminalactivity/ destruction property violence

f. Reachedmaximum time allowed in project

c'
h.
I

couldnot be metbY Project Needs with Disagreement rules/persons Death specify) Other(please
Unknown/disappeared

j
L

t2

HUD-401r 8

14. Destination. Of thosepafticipantswho left during the operatingyear (from 2c, columns I and 2), how many left fol the following yearin the second personswho left during the operating placethe destination ofchronically homeless destination? Also, please column. AII Chronic (no subsidy) PERMANENT(a-h) a. Rentalhouseor apartment b. PublicHousing

Section 8
d. e

Shelter Care Plus

houseor apaftment HOME subsidized

f.
g

or house apartment Othersubsidized Homeownership Movedin with familyor friends

persons Transitionalhousing for homeless Moved in with family or friends Psychiatlichospital Inpatientalcohol or other drug treatmentfacility

h. (i-j) TRANSTTIONAL
J

INSTITUTION(k-m)

1.

Jail/prison EMERGENCYSHELTER(n) OTHER(o-q)

n. o.
n t'

Emergency shelter'

housing Othersupportive
Placesnot meant for humanhabitation(e.g. street) Other (pleasespeci!) Death Unknown

q.

I-'NKNOWN

Explanatory Notes: provided. The responsecategories combine ldentify each parlicipant'sdestinationupon leaving the program using the categories etc.)and "tenure" (e.g., permanent,transitional,etc.). (e.g., rentalhouseol apartment,public housing, homeownership, "destination" categories befole and Consider both destinationand tenureto determinethe most appropriateresponse, be sure to look at all ofthe response category. making a selection.The table below plovides a brief descriptionof eachresponse Enter the number of participantsunder each destinationcategoryin eithel the first column of the table or in both columnsif the participantis The total number of pa$icipantsin the first column Only one reasonfor leaving should be recordedper pmticipant. chronically homeless. ("All") should equalthe number of participantsin question2c, columns I and2.

Tenure
Pennanent b. c.

Destination
Rental house ol apartment(no subsidv) Public housine

Descrintion

or withoutanysubsidy. is Participant movingto an apafiment house

Participantis moving to a public housing unit.

8 Section PlusCare Shelter house or HOME subsidized aDartmgnt

(formerly will choicevoucher knownasa Participant usea housing 8 to or Section voucher) renta house apaltment. is PlusCare Participant movingto a unit fundedby theShelter (e.s,. TBA. SRA,PRA. Section SRO). 8 Drosram
providedby the Participantis moving to a unit with rental assistance or assistance). HOME pl'ogram(tenant-based project-based

f.

Other subsidizedhouseor apartment

Homeownershio

h Transitional

Movedin with farnilyor friends

Transitional housing for homeiess people

program other by than is Participant movingto a unit subsidized some program (formerly voucher Section publichousing, housing choice 8), PlusCare. HOME. or Shelter has is Participant movingto a unit thathe/she purchased. to is and Participant movingin with family or friends expects live there for 90 davsor more.
Participantis moving into a unit funded by atransitionalhousing programfol homelesspeople (e.g., transitionalhousingfundedthrough the SuoportiveHousins Prosram). is to Participant moving in with family ol friendsand expects live there lessthan 90 days.

Movedin with family or friends hospital Psychiatric

Institution

k.

is hospital. Particinant movinsto a psychiatric

i3

HU D - 4 01 8 1

T enure

I
m n. o.

Destination Inpatient alcohol or other drug treatmentfacilitv

Description

facility. alcohol drugtreatment or is Participant movingto an inpatient is to Participant moving a iail or prison.
people. Participantis moving to an emergencyshelterfor homeless Participantis moving into supportivehousingthat doesnot correspond (a-h) and is not transitional housingcategories to any ofthe permanent (i). people suchas Section8l I housinq.* housinsfor homeless Participantis moving to a placenot meant for human habitation,such buildins. as a car, park, sidewalk,or abandoned

Jail/Prison
Emergencyshelter

Emergency Shelter

Other

Othersupportive housing

p. q. Unknown r.

Placesnot meant for human habitation

specifu) Other(please Unknown

not Participant movingto a place is thatdoes correspond anyof the to (a-p). categories above This response category should usedifyou areunsure be about where is has and theparticipant movingor if theparticipant disappeared there he/she is. is no wav to find out where

*HUD encouragesprograms to lintit the use of the "Other Supportive Housing" APRresponse category. Progrants should report destinations to housing lhat are permanent or lransitional in APR categories (a) through (h) or in categories (i) through O, respectively. Exits to enrcrgencyshelters should be reported in category (1.

15. Supportive Services. Of thoseparticipantswho lgft during the operatingyear (from 2, columns I and 2), how many receivedthe following supportiveservicesduring their time in the project? Also, pleaseplace the snppottiveservicesreceivedforchronically homelessparticipantswho lg$ during the opelatingyear in the secondcolumn, Participants may have receivedrnultiple services and all servicesshould be reportedin the table. All Chronic

Outreach b.
Case manaqement

of management) Life skills(outside case

L t.

Alcohol or drug abuseservices Mental health selvices

f.
o

HIViAIDS-related services
Other health cale seryices Education

h.

placement Housing
J
t.

Employment assistance
Child care Transportation

m, n.

Legal

specify) Other(please

l4

H U D - 4 01 8 1

objectivesfor this operatingyear (from your application,Technical 16. Overall Prosraln Go.als Under objectives,list your measurable goals listed below. Under Progress, desclibeyour progressin meeting the objectives, Submission,or APR) for eachof the three objectivesfor the next operatingyear. Under Next OperatingYear's Objectives,specif the measurable a, ResidentialStability

Objectives: Attachment 1 6 See

Progress:

Next Operating Year'sObjectives:

b.

IncreasedSkills or lncome

See Objectives: Attachment 16

Progress:

Next Operating Year''s Objectives:

c.

Greater Self-determination

See Objectives: Attachment 16 Progress: NextOperating Year's Objectives:

projectsdo answer (S/{P-^S,SO 17c. recipients answer SRO l7b. 17a. recipients recipients answer S+C 17. Beds. SHP not complete this question)
a. SHP. How many beds were included in the application approvedforr&is project under 'Current Level' and under 'New Effort'? How many of these New Effort beds were actually in place at the end of the operatingyear? New Effort in Place New Effort Current Level Number of Beds: with project funds at the end of the opet'atingyeat'? S+C. How many beds and dwelling units were being assisted (Include beds for all participants,other family members,and caregivers.) Number of Beds: Number of Dwelling Units: c. 7 3

b.

gyear? at SRO, How many dwelling unitswere beingassisted the end of the operatin personswho qualify fot'assistance.) (Include units occupiedby "in place" non-horneless Number of Dwellins Units:

l5

HU D - 4 OI1 B

Part II: Financial Information

18. Supportive Services, (SHP),this exhibitprovides Fot'$upporfive Housins information HUD on how SHPfundingfor suppoftive to services spentduring was the operating year. Enterthe amount SHPfunding of spent these on supportive services. Include HMIS costs under "Other'". For Shelter Plus-.!la!e this the services match requirement. Specify valueof supportive the LS+C), exhibittracks supportive services fromall sources canbe counted match that as thatall homeless persons received during the operatingyear, (S+C grantees should keep documentation file, including on soul'ce, alnount, typeof supportive and services.) For Section SRO, exhibitprovides 8 this information HUD on thevalue supportive to of services received homdess persons by during the year, operating

Supportive Services
d.

Dollars

Outreach Case management

Life skills (outsideof casemanagement)

$94,570.57
$8,685.66

d.

Alcohol and drus abuseservices Mental healthservices

$1,063.85

f.
5.

AIDS-telatedservices Other healthcare services

h.

Education Housing placement

Employmentassistance Child care Transportation

m. n, o.

Legal

(please Other speci[,) ASSet Management TOTAL (Sumof a throughn)

$9,930.00 $114,25A10

Cumulativeamount of match provided to datefol the Shelter Plus Care Prosram under this erant

IO

HUD-40l8 I

Operating Costs,HMIS Activities and Administration 19. Supportive Housing Program: Leasing,Supportive Services, year.For expartsion each All grantees fundingunder Supportive the Housing Program mustcomplete thesecharts operating leceiving projects: IfSHP grantfundsarefor the expansion preexisting facility,only thepeople expenditures theadditional and for ofa homeless of used expansion be included, in the originalapplication anygrantanpndments. may as Documentation resources is not required be to of with thisreport should kepton file for possible be made submitted but inspection HUD andAuditors.Do not include expenditures by any before SHPsrantwasexecuted. the Summaryof Expenditures, Enter the amount of SHP grant. funds and cashmatch expendedduring the operatingyear fol eachactivity. This tableshould up bothhorizontally and vertically. The SHP supportiveservicestotal should be the sameas the SHP suoooltive add
services Question18. in

SHPFunds

TotalExpenditures

Supportive Services Operating Costs

HMIS Activities Administlation

maynot be shownasanoperating expenss on Note: Payments principal interest anyloanor mortgage of and Sources of Cash Match. Enter the sourcesof cashidentified in the Cash Match column, above,in the following categories.Useadditional sheets.as necessarv,

Amount
Grantee/project sponsol'cash b. Local government(pleasespecify)

Stategovernnent (pleasespecif,)

Federalgovemment (pleasespecify)

Develooment Block Grant(CDBG) Communiw

Foundations(pleasespecify)

(please speciff) Private eash resources

b'

Occupancychalge/ fees Total

h.

17

HU D - 4 0 1 1 8

20. SupportiveHousing Program: Acquisition, Rehabilitation,and New Construction All grantees received that SHPfundsfol acquisition, rehabilitation, newconstruction or mustcomplete these charts theyearoneAPR in only. This exhibitwill demonstrate HUD thatthegrantee contlibuted to has enough cash at least to equally match amount SHPfunds the of spent acquisition, for rehabilitation, newconstruction. or Documentation matchinefundswereprovided notrequired besubmitted that is to
with this repolt but shouldbe keot on file for inspectionbv HUD and Auditors.

Summary of Expenditures. Enter the amount of SHP grant funds and cashmatch expendedduring the operatingyear for each activity. SHP Funds

TotalExpenditures

Cash Match. Enter the sources cash identified in the Cash Match column, above,in the following categories, Use of additional sheets, necessary. as

Amount
Grantee/proj sponsorcash ect

b.

Local government (pleasespecif,)

governnent (please State specif,)

,l

government Federal (please speciff) Community Development Block Grant(CDBG)

(please Foundations specify)

f.

Private (please cash resources speciff)

c.
n.

Occupancy charge/fees

Total

l8

HUD-40118

FOR HMIS ACTIVITIES OIVLY

(SHP).-HryISActivities 21. For Suppgrtive Housine year.Enter the lvas services spentduring operating fundingfor supportive to This exhibitprovides information HUD on horvSHP-HMIS on activities. fundingspent these tl.re amount SHP-HMIS of

HMIS Activities Ortly

Dollttrs

CentralServer(s) and Computers Printers Personal Networking

Security Subtotal

/ Software UserLicensing
Software Installation Suppott and Maintenance

Tools Soffivare Supporting , Serviies'::r Third Parties Training by Subtotal :, .'i . :l

Hoslins i TechnicalServices Programming:Customization Programming: SystemInterface Programming: Data Conversion

and Assessment SetuP Security

On-line Connectiviff (lnternet Access)' 'Facilitation

and Disaster Recovery Subtotal

Personnel
Ploject Management/ Coordination

DataAnalysis
Programming and TechuicalAssistance Training Admin isrrativeSupport Staff Subtotal :atid', HMIS SpaceCosts OperationalCosts Total

l9

HUD-40i l8

Describeany problemsand/or changesimplementedduring the operatingyear.

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

20

HU D - 4 0 1 1 8

Persons Served Worksheet - HUD Annual Progress Report of or (PPI)on thisfonnis donewith theknowledge consent theclients.The lnformation of Personal Collection theProtected PPI is only usedfor thefoilowingpurpose: (APR)for theContinuum Care(CoC)Homeless Assistance Program in Accurate completion theAnnualProgress Report of of whichtheclientis enrolled. you the Thisworksheetoptional is intended help collect needed complete Annual to Progress Report. instructions and is and to information Codes follow. notsubmit worksheet HUD. Do this to
Relationship Number Monthsin of (calculate) Project l2a Number Monthsin of -Participant Project did not leave (calculate) t2b Non-Homeless (l Only) ( Y/N ) 4

Persons Ser-ved Worksheet (continued) (PPI)on thisfonn is donewith theknowledge consent the clients.The or of Information Personal of Collection the Protected PPI is only usedfor thefollowingpur?ose: Program in of Assistance Reporl(APR)for theContinuum Care(CoC)Homeless of completion the AnnualProgress Accurate whichthe clientis enrolled.
to Do not submitthis worksheet HUD
No.

Veterans (YAI) Sratus 6a

Chronically Homeless

ryn-J)
6b

Ethnicity (code) 7

Race , (code) 8

SpecialNeeds (code) 9a

SpecialNeeds (code) 9b

Prior Living Situation 10

Monthly lncome At Project Entry 1la

Monthlylncome At Project Exit Itb

2l

HUD-40118

22

H U D - 4 0 1 t8

Persons Served Worksheet (continued) Collection theProtected of Personal Infotmation (PPI)on thisform is donewith the knowledge consent theclients.The or of PPIis only used thefollowingpurpose: for Accurate completion the AnnualProgress of (APR)for the Continuum Care(CoC)Homeless Report program of Assistance in whichtheclientis enrolled.
Do not su bmit this worksheetto Reason Leaving for (code) Program l3

lnstructions Codes Persons and for Served Worksheet

T he use o f this wo rksheet is opt ional. I t was des ign e d t o help you co llect info r m at ion on par t ic ipant s need e d to comp lete th e Ann ua l Pr ogr es s Repor . t . I f t he w orksheet is u pd ate d a s par t ic ipant s m ov e in and m o v e out of yo ur p roje ct, mo s t of t he inf or m at ion r equir ed for comp letio n will b e c ont ained in t he wor k s heet , D o n ot subm it th is worksh eet wit h t he APR. For projects tha t se rve f am ilies , HUD only r equir es r eporting o n th e n umb er of c hildr en s er v ed, and t he age and ge nd er o f th ese c hildr en. O nly nam e, r elations hip , da te o f b ir t h, and age on t he wor k s heet z)

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 t h 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 l y m e m b er . U s e t h i s n u m b e r to transfer to the other pages ofthe worksheet. Beginning with number 4, the numbers in the columns 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 nte r th e specific "Other" answer for inclusion in the ApR. Participant Number. This column allows you 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 assign a case number. One number should be assigned to each adult

HUD- 40118

Name. Name s o f p ersons will not be r epolt ed t o HUD . T he u se of n ame s is f or y our r ec or d k eeping conven i en ce . Relat ionship . En ter th e appr . opr iat e r elat ions hip. Examples in clu de : Self, Head of hous ehold, Spous e, c hild. Ent ry Date . Ente r da te par t ic ipant ent er ed t he project . Usu ally th is will be t he dat e of ac t ual physical mo ve -in for a hous ing pr ojec t . E xit Date. Ente r d ate p ar t ic ipant I ef t t he pr oi_ec t . Usually this will b e the dat e t he par t ic ipant p hysically mo ve d o ut fo r a hous ing pr ojec t . Do not i nclude a p articipa nt wh o t em por ar . ily lef t t he pr ojec t a nd is ex pe cte d to re tur n in les s t han 90 day s ( e. g. , h o spit al izati o n). 4. I ncom e -elig ible Non- hom eles s in SRO . The SR O prog ra m a llows a ss is t anc e t o unit s oc c upied by S ection 8 in co me-e ligible per s ons r es iding at t he S R O prio l to reh ab ilit at ion. For SRO pr ojec t s only, in dicate whe ther t he par t ic ipant is an incom e -elig ible , n on- hom eles s per s on ( y ) or not (N ). SHP an d S+C p r ojec t s s hould s k ip t his it em .

a. Mental illness b. Alcohol abuse c. Drug abuse d. HIV/AiDS and related diseases e. Developmental disability f. Pirysical disabilities g. Domestic violence h. Other (please specify) 9 b . E n t e l 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 s ab 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 t h a t b e st d e s c r i b e s w h e l e t h e p a r t i c i p a n t s l e p t i n t h e we e k prior to entering the project. Do not double c ou n t . a . 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 t c .) b. Emelgency shelter c. Transitional housing for. homeless persons d. Psychiatric facility* e. Substance abuse treatment facility* f. Hospital* g. Jail/prison* h. Domestic violence situation i. Living with relatives/friends j. Rental housing k. Other (please specify) *I f a p a r t i c i p a n t c a m e f r o m a n i n s t i t u t i o n b u t w a s t h e r e I e s s t h a n 3 0 d a y s a n d w a s i i v i n g o n t he s t l 'e e t o r i n a n e m e l 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 t h e str e e t or shelter category, as appropriate.

5 a . D ate o f Birth . En ter dat e of bir t h inc ludins month, da y, a nd yea r . 5 b . A ge. Ente r a ge a t e nt r y . 5 c. Gend er. En ter a pp r opr . iat e let t er f or gender . M-Male F- Fema le. 6 a. V ete ran s Sta tus, I ndic at e if t he par t ic ipant is a veter a n. Plea se n ote: A v et er an is any one who has ever b ee n o n ac t iy e m ilit ar y ' dut y s t at us f or the Unite d State s. 6 b. Chronically ho mele s s per s on. I ndic at e t he numbe r o f p articipa nt s t hat ar e c hr onic ally homele ss. 7. E thnicity. Ente r a ppr opr iat e let t er f or . et hnic group . a. I {is pa nic o r L atin o b. No n-Hispa nic or Non- Lat ino R ace . Ente r a pp rop r iat e let t er f or r ac e. a. A m e lica n In dia n or Alas k an Nat iv e b. A sian c. B la ck o r Africa n-A m er ic an d. Native Hawa iian or O t her . Pac if ic I s lander e. W hite f , A m e rica n Ind ian /Alas k an Nat iv e & W hit e g. A s ian & Wh ite h. B la ck/AfLican Am er ic an & W hit e i. A merican Ind ian /Alas k an Nat iv e & B la ck/Aflica n Amer ic an j. Oth er Mu lti-Racial

Instructi on C o d e s f o r P e r s o n s S e r v e d W orksheet ( c o n t i n u e d )
I I a,Gross Monthly Income at Project Entry. 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 t he 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. 1 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 . E n te r the gross monthly income the participant is receiving when exiting the project. I I c.Income Sources Received at Project Entry. E n t e r a l 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 a n t is receiving at entry to the project. a. Supplemental Seculity 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 S D I) c. Social Seculity d. General Public Assistance e. Tempofary 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
.A

B.

9 a. S pecial Nee ds. En ter t he let t er ( s ) f or t he cat ego ry(ie s) th at d es c r ibe t he par t ic ipant ' s disability(ie s). (You m ay double c ount )

H UD - 4 0 1 1 8

I l d .In com e S our c esRe c e i v e d a t Pro j e c t E x i t. En te r all t y pes of in c o m e th e p a rti c i p a n t i s ran ei.,in 4i rvvun r y r r . E hr ^i-v . udt e x i t. (U s e c o d e s a s i n I l c .) or y r . 1 12 a L e n g t h in S t ay in P ro g ra m . C a l c u l a te di te m. (Se eE nt r y Dat e and Ex i t D a te a b o v e .) l2b . L e n gt h of S t ay in Pro g ra m. (P a rti c i p a n td i d n o t leav e dur ing t he o p e ra ti n gy e a r. H o w l o n g h a vet hey beenin t h e p ro j e c t? ) 13 . R e a s onf or Leav ing P ro j e c t. En te r th e p ri m a l y l 'e a s on why t he par t i c i p a n t l e ft th e p f o j e c t. (Co mplet eonly f or p a rti c i p a n tsw h o l e ft th e p l o j e c t and ar e not e x p e c te dto re tu rn w i th i n 9 0 days. a, Left for a housing opportunity before co rnplet ing he pr og ra m t b . Com plet edpr ogr a m c. N on- pay r nent r e n t/o c c u p a n c y h a rg e of c d . N on- c or nplianc e i th p ro j e c t w e , C r im inal ac t iv it y /d e s tru c ti o n f p ro p e rty / o vi o l enc e f. R eac hed ax im u mti me a l l o w e d i n p ro j e c t m g . N eedsc ould not b e m e t b y p ro j e c t h . D is agr eer nent h ru l e s /p e rs o n s wit i . Deat h j . Oth er ( pleas es pe c i fy ) k. Unk nown/ dis app e a re d

15. S upporti ve S ervi ces. E nter al l typesof supporti veservi cesthe pal ti ci pantrecei ved ur ing d the ti me i n the proj ect. a. Outreach b. C asemanagement c. Li fe ski l l s (outsi deof casemanagement ) d. A l cohol or drug abusesel vi ces e, Mental heal th servi ces f, H IV /A ID S -rel atedservi ces g. Other heal th care servi ces h, E ducati on i . H ousi ng pl acement j . E mpl oymentassi stance k. C hi l d care L Transportati on m. Legal (please n. Other specify)

14 . D e st inat ion. E nt er th e d e s ti n a ti o no fth o s e l e a vingt he pr ojec t . Pe rma n ent : a. Rent al hous eo r a p a rtm e n t(n o s u b s i d y ) b. P ublic Hous i n g c . S ec t ion8 d. S helt erP lus C a re e. HO M E s ubs i d i z e dh o u s e o r a p a rtme n t f. O t her s ubs id i z e dh o u s e o r a p a rtm e n t g. Honr eowne rs h i p h. M ov ed in wi th fa m i l y o r fri e n d s Tra ns it ionall i. T r ans it ionalh o u s i n g fo l h o m e l e s sp e rs o n s j . M ov ed in wit h fa m i l y o r fri e n d s In stit ut ion: k . P s y c hiat r icho s p i ta l , l. I npat ientalc o h o l o r d ru g tre a tm e n tfa c i l i ty rn. J ail/ pr is on En re r gen y : c n. E m er genc y h e l te r s O t h er : o. O t her s uppo rti v eh o u s i n g . p . P lac esnot m e a n t fo r h u m a n h a b i ta ti o n (e. g, , s t r eet ) q . O t her ( pleases p e c i fy ) U n known: r. Unk nown

25

HUD-401l8

HazelBetsey Apartrnents CA Reporting efiod't 1I 06 - 61301 P | 07 cAO1 I 044 c50 16. Overall ProgramGoals.

Residential Stability: fbl of will in PIuscarehousing at least year'. one Objective: 66Vo theparticipants remain Shelter Progress: PlusCarehousing at least year'. Achieved.66% (2 of 3) of participants remained Shelter in for one will Next Operating Year'sObjective: 660/o thepafticipants remain Shelter in PlusCarehousing at least for of oneyear. will Pluscare housing at least for two years. Objective: 66%of theparticipants remain Shelter in in PlusCare housing at least years, Progress: Achieved.66% (2 of 3) of participants remained Shelter for two will in PlusCarehousing at least NextOperating Year'sObjective: 660/o thepalticipants remain Shelter of for two yeals. Increased Skillsor Income: part year. of dulingtheoperating 33o/o participants eitherenter continue or full-timeemployment will or parl eithet' entered continued or full-timeemployment or during Achieved. 33%(l out of 3) of participants year. theoperating palt employment NextOpelating will or duringtheopelating Year'sObjective: 33%of participants either enter continue ol part-time Objective: Progless:
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program and/ot'a vocational or an training duringtheoperating 33o/owill eitherenter continue educational year. entered continued educational or an and/olvocational Not achieved. Noneofthe threeparticipants Progress: participant year. Oneparticipant workingfulltime. Another was trainingprogram duringthe operating to that shewasvolunteering shewasableto while caringfor her small child. Staffcontinues as reported program.Staffassists participants entering participants enteran educational vocational in or to encourage ifparticipants showan interest doingso. in into an educational and/or vocational trainingprogram enter continue educational ot' an and/ora vocational training 33oh will eithEr Next Operating Year'sObjective: year. program duringtheoperating Objective: GreaterSelf-determ ination: will and with dlug and/oralcohol addiction be clean sober. 33%of those alcohol addiction haveremained clean sober. and with drugand/or Achieved. 66%(2 of 3) of pa*icipants Sponsors a varietyofhannreduction use lesidents who seek access treatment. to to Staffcontinues assist participants maintaining in theirhousingor their well-being. to strategies assist will addiction beclean andsober. with drugand/or alcohol NextOperating Year'sObjective; 33%of those Objective: Plogress: will with theirchildlen by who 66%o households needto leunifywith theil children, bereunited of placement Shelter in PlusCalehousing, as Progress: No reunification required. who will of to 660% households need reunifywith theil children, bereunited Next Operating Year'sObjective: by in PlusCarehousing. with theirchildren placement Shelter parents retaincustody andcare theirchildren. for, of, ofparticipant will Objective: 660/o All participants maintained custody theirchildren. of Progress: parents retaincustody andcatefor theirchildren. will of, Year'sObjective: 660/o participant of NextOperating Objective: