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(exp.

l1/30/2009) No, OMBApproval 25060145

of U. S.Department Elousing and {JrbanDevelopment Office of CommunityPlanning andDevelopment

RePort(APR) Annual Frogress


for SupportiveHousingProgram ShelterPlusCare and Section8 ModerateRehabilitation for SingleRoomOccuPancY (SRO)Prograrn DweXlings

HUD-401l8

Fublic reportingpurrlenfor thiscollection per ofinformation estimated avcraBe hours response, is to 33 including time for reviewing the instructions, searching existing gathering rnaintaining dataneeded, completing reviewing collection information.This agency datasources, atrd the and and the of n:ay not conduct sponsor, a person not required respond a collection or and is to to, ofinformation unless that collecbndisplays validOMB control a number,

General Irsstructions Purpose,TheAnnualProgress Report(APR)is a reporting thatHUD uses h'ack tool to program progress and accomplishments informthe Deparlment's and competitiveprocess homeless for assistanca funding. Filing Requirements, Recipients HUD'shomeless grantsrnustsubmit2 APR'S to HUl]'ithin 90 days of assistance after the end of eachoperatingvear. Onecopyof thereportmustbe submitted tJreCommunity to Planning Dwelopment and (CPD)DivisionDirectorin the locaiHIID FieldOfficeresponsible managing grant. The othercopymustbe submitted for the to HUD Headquarters, Department Housing UrbanDevelopment, of and Aftn: APR DataEditor,Roomi262, 451?hStreet, SW,Washington, 20410. Faiiureto submitanAPR will delayreceiving DC. grantfundsandmay resultin a determination of lackof capacity futurefunding. An APR mustbe submitted eachoperating for for yearin whichHUD fundingis provided. Grantees received that SHPfundingfor new construction, acquisition, rehabilitation required operate or are to theirfacilities for 20 yeals.Theymustsubmitan APR 90 daysafterthe endof thefirst operating yearandevery thr.oughout 20 years. year the A separate repoftmustbe submitted eachHUD grantreceived. Shelter for For PlusCare(S+C), separate mustbe a ApR submitted each for S*C component. For those grantees receiving extension, separate an a reportcovering periodmustbe that (see submitted Extension below). Recordkeeping. Grantees mustcollectandmaintain information each participant orderto complete ApR. Optional on in an worksheets attached.The worksheets are may be usedto recordinformationmanuallyor to designa Computerized system to store tabulate information.Theworksheets and the should besubmitted HUD with theApR. not to Organizationof the Report. The APR is organized the following manner: in Part I: ProjectProgress. This portionof thereportdescribes progress movinghomeless the in persons selFsufficiency, to documenting services received, listingprojectgoals, accounting beds/units, and for Part II: FinaneialInformation. Thisportionof thereportis completed ail grantees by receiving fundingunderSHp,S+C, andSRO. Final Assembly Report. After the entire of repo$is assembled, numbereverypagesequentially. Mark anyquestions do . that not applyto your program with "N/A" for not ipplicable.(See Special Instructionsfor Projects SSO below.) Definitionsof Client/Household Types. Eachclient/household is defined type below,Notethata client'sclient/household fypeshould based the client'sageandlor be on household composition theprogramentrydateclosest thestartofthe al to year. operating Families A family is a household composed two or morerelated of persons, leastoneofwho is a chiid accompanied at by an adultor ajuvenileparenL Singles in Families- Persons accompanied children, not not by including pregnant womennot accompanied other by children unaccompanied and youth,aresingles in families. not Whentwo adults fwo unaccompanied or youthpresent together services, for eachperson should counted singles in families..Clients'household be in not status shouid be determined based their household on composition theprogmmenfrydateciosest thestartof theoperating at to year. This rleansthatpregnant womenexpected givebirth duringtheirprogram to stayshouldstill be counted singles in as not families. Adults in Families Within a family,anadultis anyperson yearsof ageor older. For thepurposes ApR reporting, l8 of the determination whethera person an adultin familyshouid madebased theirage household of is be on and composition at theprogram entrydateclosest thestartofthe operating to year. Cltildren in Families- Childrenin Families defined children are as underthe ageof l8 accompanied oneor more by (parent, adults relativeor guardian). Children families in alsoinclude botha juvenileparent theparint'schild(ren). and For thepurposes APR reporting, deterrnination whether person achildin family should made of the of a is be based on theirageandhousehold composition theprogram at entrydateclosest the startof the operating to year.For example,
H U D- 401r 8

during entry(ifthey entered year day of who areless thani 8 years ageon ihe flu'st ofihe operating or at program clients yeat year)shouldbe countedaschildrenevenif thry tun'r18 duringthe courseof the operating . the operating in and adults families children families. in in Persons Famities Persons familiesincludes in

in termsareapplied Otirer Key Definitions. differently Thefollowingtermsareusedin theAPR. As indicated, somecases, depending whether fundingis from SHP,S+C,or SRO. on the person HUD delures chronically person "an unaccompanied Chronicallyhomeless as a homeless homeiess individual with a disabling who haseitherbeencontinuously homeless a yearor moreORhashadat least for condition four(4) episodes homelessnessthepastthree(3) years."To be considered of in chronically homelesq person a musthavebeenon (i.e, not in transitional thestreets in an emergency or shelter housing) duringthese stays. personis FIUD'sdefinition a chronically homeless of based thefoilowingcomponents on e Unaccompanied anunaccompanied homeless individual thesame has homeless individual: characteristics above). of a Single in a Family(described not r Disablingcondition:seethe instructions (below)to determine disabling condition under whether clientis a disabled. year. Did not leavetlre program- Thistermrefers clients to who werein theprogram the lastdayof theoperating on condition (l) A disability defined Section of theSocial as: as in 223 Disablingcondition- HUD defines disabling a which is (a) expected be of longcontinued indefinite to SecurityAct; (2) a physical,mental,or emotiondimpairment and and an duration,(b) substantially impedes individual'sability to live independently, (c) of sucha naturethatsuchability (3) housingconditions; a developmental disability asdefmedin section102of the could be improvedby moresuitable Act; (4) thedisease acquired of immunodeficiency Disabilities Assistance Bill of Rights and syndrome Developmental or immunodeftiency any conditions for syndrome; (5) a diagnosable arisingfrom the etiologicalagency acquired or substance abuse disorder, program, services. a residential Enteredthe program- Entered program the refers thefirst daya clientreceives to For housing For services, datemayrepresent day in this this datewould represent first day of residence theprogram's the the ptrticipation a service the of programenrollment, day a servicewasprovided, thefirst dateof a periodof continuous or in (e.g.,daily,weekly,or monthiy). participant stafts receive to For S+CandSROprograms, program the entrydateis thedatethatthe rental assistance. For provided priorto this point arerecognized necessary outreach/enrollment areeligible countas and as for to S*C, services match. and an of to that An ExtensionAPR applies SHPand S+C grantees requested received extension their granttermfrom periodandtheregular between APR for theextension an theHUD freldoffice. Theonly difftrence APR(besides the page. Grantees shouldcircle"yes" to indicatethe APR is for an extension amountof time covered) the signature is yearfor whichthereportis extension. example, the grantee extending 3, periodandcircletheoperating an For year if is APR for the extension period,indicating shouldsubmitan APR asusualfor year3 andsubmitanother the grantee the page. is second an extension alsocilclingyear3 on thesignature and of a Granteemeans directrecipient the HUD award. For program, date refers thelastdaya clientreceives to services. a residential Left the program- Left theprogram this For the in housing. services, exit datemayrepresent lastday the wouldrepresent lastdayof residence the program's the Service, a clientleaves program If a service wasprovided the lastdateof a periodof continrcus the (e,g., or temporarily but do for a hospitalization) is expected returnwithin30days, not countthatclientashavingleft theprogram. to For S+Cprograms, programexit daterefersto thedatetheparticipant the stopsreceivingrentalassistance is not and expected return S+Cassisted to to housing.if theparticipant refums S+Cassisted to housing within 90 days,the person shouldnot be considered exiting from the program.f theperson as returns S+C assisted to housingafter90 days, that person considerednewparticipant, is a The worksheet designed capfure information. is to this
3 HUD_40il8

Match for S+Cis the valueof supportive services received participants the S+Cpojectwhich,in theaggregate, in by mustat least equal valueof the S+Crentalassistance the provided overthe life of theproject.For SHP, matchis cash usedtoprovidethe grantee's porlionof acquisition, rehabilitation, construction, new operatiors supportive and services expenses. Operatingyear* For SHPprograms, first operating begins the year afterdevelopment activities acquisition, for rehabilitation, new construction complete, and are aftera copyof the Certificate Occupancy sent thelocalH1ID of is to office,andwhenthe first participant accepted theproject.For projects is into withoutacquisition, rehabiiitation, new or construction, operafing the staftdatebegins whenthegrantee accepts first participant. dedicated the For HMISprojects, the operating begins year whenany eligiblecostincluded theapproved in projectbuiget is incuged, S+C(SRA, For PRA andTRA components), first operating begins thedateIIUD signsthe grantagreement. the year on For S+C/SRO andfor Sec'8 SRO,the first operating yearbegins with theeffective payments dateof thJ Housing Assistance (HAp) Contract. To determine whichoperating yearto circleon theAPRcover page, begincounting fi'omtheinitialgrantoperating start dateandinclude renewal grants.For example, project a receiving initialgrantfor threeyears u r.n.*ul grint for an und two years wouldcilcle yearsl, 2, and3 respectively theAFRcoversheet the initial grantandwouldcircle on for 4 and5 respectively therenewalgrant' For any futurerenewal for grants, grantee the wouldbeginly circling6 ontheApR cover sheet. Participants Thetetm pafiicipant refers Singles in Families Adultsin Families defrned to not and as above.participant doesnot include childrenor caregivers live with theadults who assisted. ProjectSponsor meansthe organization responsible canyingout thedaily operation theproject, the for of if organization an entify otherthanthe grantee is

ons for e.UqIy (SS()) Programs. SSOgrantees should complete questions, all unlessa written agreement beenreachedwith the field office concerningwhich questionscan be answired has using estirates, or in rareinstances, skipped. Below is an example how infotmation of couldbe derived a large, in singloservice project: SSO A grantee/sponsor membercouldbe assigned collectinformation staff to from theorganizations housing participants. the The staff person wouldcontact theseindividualorganizations request to information regaidiog thepersons thatiacilitythatuse in the service' participants For living on the street, grantee/project the sponsor mayprovide estimates. Information couldbe collected eachparticipant for participants for or receiving services a point-in-time. estimates at If or point-in-time counts used, methodusedmustbe described theAPR andthedocumlntation are the in kepton file. As with all projects funded under HUD's homelessness assistance grants, grantees operating SSOprojects expected are to complete APR questions areapplicable them, Notethatall projects all that to havebeenawarded fundsasa result of responding theprogram to goalsof assisting persons hcrneless obtajn/remain permanent in housing increase skillsand and their income,TheAPR documents theirpr.ogress meeting in these goals. In somecircumstances officesandgrantees field may signa writtenagJeement concerning questions canb answered that using estimates, in rareinstances, or skipped.Seethe special instructions belowfor reporting special oi lypesof projects, such as outreach only projects, projects providingservices children to only,andtransportation, medical, dental, and'other sinlte,shortduration service projects. SSo programs a thirdpriority for localHMIS irnplementation, are followingemergency sheiters, transitional housing programs, programs, petmanent outreach and supporlive programs. housing OnceSSOprog.umr-ar" included theHMIS, SSbgrantees in will be ableto answer APR questions all usingtheirHMIS data.SSo granteei arenot yet participating HMis will need that in to collectdatato answer APR questions the usingthe special inshuctionsprovided above. Outreach Only Projects. Projects which aresolelydevoted street to outreach connection housing services and to and are not requiredto traokparticipants beyondtheir contrctwith persons the street.It is sufficientfor these on piojectsto enter
H U D - 401l8

giventhat for questions 11-13 17). Estimates questions5-9 are allowed, and 1-10 information questions (skipping on questions. personal participants bereluctant answer to may providing of number people, basic is the that will Anslveling questions demonstrate the grantee serving appropriate the persons beingserved, the of are demonstrating types demonsfrating homeless that demographic for information Congress, participants connected andthetypeofservices to, theyarereceiving. housing are grantee parlicipant often but between and F{otline Projects. Hotlineservices similarto outreach are only projects, contact is of veryshortduration people It for projects answer enterandleave program the nearly simultaneously, is sufficient these to questions (skipping 10,andl4-19(skipping 4), l-5 17). Projects Providing Services Children To Only.Projectsthat providechild care,after schoolcare,counseling children, for etc,makean importantcontribution towardmovinga familyout of homelessness. While the mainfocus theprojectis of providingservices the children,it is the adultswho are reportedon in questions to 6-16of the APR. Like all other projects, typeis alsotargeted this towardgetting families the into housing the and increasing families' incomes. (except Grantees skipquestion all otherquestions may 9; should answered be 17). Transportation, Medical, Dental, and Other Single, Short-Duration Service Projects. Some grantees provide a persons obtain/remain permanent singleservice fairly shortduration focused homeless of ONLY indirectly assisting on to in projects enterinformaion questions and14housing increase It and theirskillsandincomes. is sufficient these to for on 1-10 i9 (question maybe skipped), However, with transportation services, is unreasonable think thatsomeone it 17 to wouldhave to give their age,race,andethnicityto a bus driverto get a ride a few blocks providea nanative, For these whichgivesthenumber ridesgivenduringthe operating year,andprovides services, of estimates on theabove statistics based thepopulation utilizes service. on that the should reporton all participants Special Jnstructions For Safe Haven (SH) Proiects. Grantees served during the year. Note: this is a change from prior instructions operating wheregrantees wereinstructed reporton the first 25 to participants served. SDecial Instructions for Homeless Management Information Svstem IHMIS) Proiects. HMIS grantees should outthe coversheet theAP& PartII Financial fill of lnformatioqandtheHMIS Activitiessection.

HUD-4OI I8

PAGE - TO EE COMPLETEDBYAI.L GRA]YTEES THXS


uranlee:

of Services Department Human of CityandCouniy SanFrancisco,


Project Sponsor:

or Number HUD Grant Project cs0 cAO1 I 038


ProjectName:

Center Housing Affiliate the BernalHeightsNeighborhood of Services


yearbeingreported or) OperatingYear: (Circletheoperating

Betsey Hazel Apts.- Studio


ReportingPeriod: (monthday I lyear)

trr Jz n: X4 ns no trz ns ns Dto nrr nrz n r3 D l 4n rs nro ntz l ts [ts l z o


Indicate extension: n Yes X No if Indicate renewal: if fi ves I No
PreviousGrant Numbers for this proiect:

from:B/1/06

to7l31l07

cAO1 040 c401 cAO1 c301 038 cA39C940041

Check the componentfor the program on which you are reporting.

SupportiveHousing Program (SHP) n I


I I

PlusCare(S+C) Shelter n X ! ! (TRA) Tenant-based Rental Assistance (SRA) Assistance Rental Sponsor-based (PRA) Assistance Rental Project-based (SRO) Single RoomOccupancy

Section Moderate 8 Rehabilitation n SingleRoomOccupancy (Sec. SRO) 8

TransitionalHousing Permanent Housing for Homeless with Disabilities Persons


SAIE HAVEN

D N -

Housing Innovative Supporlive Only Supportive Services HMIS

this with a descriptionof population,number servedand accomplishrnents operatingyear) Summary of the project: (One or two sentences

provided to six unitsof permanent housing homeless to families. the All year,this project up thisoperating During and had one or more specialneedsrelated mental to shelters camefrom eitherthe streetsor emergency families use,and/orHIV/AIDS. substance health,
N am e& T itl e o f t h e P e r s o n w h o ca n a n swe r q u e stio n sa b o u tth isr e p ort: P hone: (i ncl udeareacode)

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


Address:
Fax Number: (include area code)

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

(415)648-0793

i hereby certify that all the information stated herein is true and accurate.
g Warning: HUD will prosecutefalse claims and statements.Conviction may result in criminal andlor

10 1 0l.0 l 2: 3l U. S . C. 37 2 9 .3 8 0 2
Name & Title of Authorized GranteeOfficial: Signature& Date

& Grants Ana Official: Project Sponsor NameandTitle of Authorized


Adviento. ShelterPIus Care

re frafoT

Director of Lauderback-Strebler, Justine Finance Admin. and

wltvft
HUD-40r 8 r

(EXCEPT HMTS) BY PARI I. TOBE COMPLETED ALL GRANTEES


OT',1 TNSTRUCTTONSPAGE3 OF THE APR SPECTAL FLEASESEE SSO GRANTEES, Part I: Froject Progress recent comes most CoC i-nformation fromthe at to Level Persons beserved a givenpointin tirne. (This of 1. Projected
2

lcatlon. Number of Not Singles in Fanrilies


b

Proiected Level at Persons be served a givenpoint in time to

of Number Adultsin Families

Number of Children in Families

Number of Families

year. duringthe operating 2. Persons Served


Number of Singles in Not Families
a,

Numberof Adultsin Families

Number of in Children Families

Number of Families

year Numberon the ltrst day of the operating year programduringthe operating Numberentering year during the operating Numberwho left the program

b.

0 0
h

d.

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

notes: Explanatory as Not whichclients shouldbe counted Singles in to above determine Instructions Typesin theGeneral of SeeDefinitions ClienVHousehold in type for and Aduits in Families, Childrenin Families.Note thatthistabledoesnot account changes client/household thatmay Families, type on a be year. Insiead, eachclientshould assignedsingleclienVhousehold based theclient's ofthe opelating occurduringthecourse year. In this way, eachclientis counted ta composition theprogram entrydateclosest thestart ofthe operating at and/orhousehold age only oncein the table. in be who shor:ld counted rowsa-d: to Usethe following graphicandexplanations determine

in on Client progrsm lirslday of year,leffdudng ths oprating ysEf,counlin 2a snd2c. on Client proglam lirslday in year olopsraling and la8l yBar count dayof oFBraling in 2a and2d. rH
H

Entefed leff and CliPnt program duringoPeraling yesr:countin ?b and2c. pfogram during Clisnt BntBrsd year operaling and6lillin year program lasl dayof on counlin 2b and2d.

and Client entered left program befDrestart of ysan do not counlin opsr8ling qua6tion 2.

FlEt d8y of thg operallng year

Lasl day oftho ysar oFeratlng

a.

the before first dayofthe the who entsred program all Numberon the first day ofthe operatingyear:Thisrow includes clients year. yearanddid not leavethe programuntil afterthe first day of the operating opetating who entered program or after first the all the on Number enteringthe programduring the operatingyear: Thisrow includes clients year. For clients with multipleprogfam entrydates, the use the year, to andincluding lastday of theoperating up dayof theoperating the morethan year.Do not counttheclientmorethanonceevenif hdshe entered program to entrydateclosest the startof tl-leoperating year. onceduringtheoperating on year; This row includes clients who lefttheprogram or afterthefirst dayof the all Numberwho left during the operating with multipleprogl'am dates, theqxitdate exit use year.For clients year,up to andinctuding lastdayof theoperating the operating
HUD40l 18

b.

during morethanonce the the year.Do not count clientmorethanonceevenif hdsheexitsd plrogram closest theendof theoperating to tbe operating Year. d. as whowerein theprogram of thefirst all year; This row includes clients in Nunnber the progranron the last day ofthe operating of year.Thenumber year the dur.ing operating and whodid not leaveduringtheoperating or dayof theoperatinglear who entered 2c' b on yearis calculated based theresponsesrows2athrough For on in or clients families theprogram thelastdayofthe operating of the in or of in or of acld each column, thenumber clients families row 2a to thenumber clients families row 2b andsubtract number 2d= in or clients families row 2c. Therefore, 2a+ 2b-2c.

3.

Project Capacity.
of Number Not Singles in Families o o of Number Adultsin Families Number of in Children Families Numberof Families

Number on the last day (from 2d, columns I and 4)

b.

Number proposedin application (from 14 columns 1 and 4) CapacityRate (divide aby b): %

.tt,'1,;

;1.
j :::.ti ;:..':j ::t'

100 %

l-:" 'ili''

ii

0%

ExplanatoryNotesr is coc applicationfor whichthe program reporting. Row b refersto the mostrecent

8 for is persons. This question to be completed Section SROprojects,Not Applicable 4. Non-homeless


yeat? duringtheoperating persons by werehoused theSROprogram non-homeless fto* *uny incomeeligible

year,how manypeople in thefollowingage are during operating the S. Age and Gender. Of thosewho enteredtheproject andgendercategories?
(from 2b. column I SinslePersons b.
u.

Age 62 and over

Male

Female

51-61

3l-50 t8-30
17andunder

(from 2b' colurnns & 3) 2 in Persons Families

t.
o

62 and over

h.

m.

5l -61 3l -50 18-30 13-17 6-t2 1-5 UnderI

ExplanatoryNotesl year, Only clients duringtheopelating who entered program the in and not refers only to Singles in Families Persons Families This question to Peisons be underSingle should equal the repofted of in criteria be counted thistable.Thetotalnumber clients can these who meet to in shouldbeequal thesumof underPersons Families of reporled 2b, in reported question column1. The totalnumber clients number 2b. 2 columns and3 in question Answer questions6 - 10 only for participants who entered the project during the operating year (from 2b, columns 1 &'2). The term participant meansSinglesnot in Familiesand Adults in Families. It does not include children ol'caregivers.NOTE: to 7, The total for questions, 8 and 10 below should be the same;respond each of those questionsfor all participants. Someof

who for information individuals arryhntnicl1lly-homeless, the listed thequestions tbroughout APRwill beasking
HUD-401 l8

6a. Veterans Status. A vetel'anis anyonewho has ever beenon activemilitary duty status' wel'e veterans? How many participants |t

been continuously who haseither condition a disabling homeless individual person An unaccompanied 6b. Chronicallyhorneless "vith (3) in of four (4) episodes homelessnessthepastthl'ee years.To be considered for homeless a yearor moreOR hashadat least (ie. housing) during shelter nottransitional or musthavebeenon thestreets in anemergency homeless person a chronically undet' General the Instructions homelessness, OtherKey Deftnitions see of of these stays.For furtherdiscussion the definition chronic above. individuals? were How manyparticipants chronicallyhorneless ft-*f

7.

Ethnicity. How many parlicipantsare in the following ethnic categories?

b.

Hispanic Latino or Non-Hispanic Non-Latino or

Explanatorylt{otes: equal number parlicipants of in the of The be Eachparticipant should listedin only onecategory. totalnumber parlicipants thistableshould 2b, I in question columns and2.

8.

are Race. How manyparticipants in thefollowingracialcategories?


American Indian/Alaskan Native Asian Black/African American

b.
u.

Pacific Islander NativeHawaiian/Other White


American Indian/Alaskan Native & White BlacVAfrican American & White

I.

s. Asian& White
h.
t.

American Indian/Alaskan Native& BlacVAfrican American OtherMulti-Racial

ExplanatoryNotes: to not a i be whose racedoes correspond categoriesthrough should be should listedin only onecategoly.A participant Eachparticipant equal number pafticipants question the of in 2b, in of in counted j, OthelMulti Racial. The totalnumber participants thistableshould the categories. you maycombine catogories generate APR response to HMIS raceresponse I columns and2. If usingHMIS data,

may Participants havemorethanone. havethefollowing? Needs.How manyparticipants 9a. Special the For also condition, indicate number categories. each If so,countthemin all applicable thatwerechronicallyhomeless, All Chronic a. Mentalillness Alcoholabuse b. Drueabuse c.
A

HMAIDS

and related diseases

t
o

disabiliw Develoomental Phvsical disabilitv


Domestic violence

h.

specifu) Other(please

ale 9b. How manyof theparticipants disabled? tf ExplanatoryNotes: Condition" under OtherKey Definitions theGenerzl in see of meetHUD's definition "disabled," "Disabling whichparticipants To determine Instructions. 9 HUD-40118

the weekprior to entering project? (Foreach in slept I0. prlor Living Situation-How manyparticipants in thefollowingplaces the 2b, in of equal number participants question the in of parricipant, one choose place.Thetotalnumber participants the"Alli iolumn should (Choose one) slept participants in thefollowingplaces. how manychronicallyhomeless indicate tolu*ns I and2). A1so, All
Non-housine (street,park, car, bus station,etc.) Emersencv shelter Transitional housing for homelesspersons Psychiatlic facilify* abusetreatmentfacility* Substance Hospitalt
1' .i1, a.-..,

Chronic

c.
,l

f.

s
h.

Jaillorison*
Domesticviolencesituation

., .r i :i ' ., :t

:, ,.;,1:,::.;.
...:j ;. . j. :rr : .r

|.

Livine with relatives/friends Rental housine


Other (pleasespecifv)

*If a participant camefrom an institution(psychiatricfacility, substance abusetreatmentfacility, hospital,or jai|, but was there lessthan shelterbefore enteringthe treatmentfaciiity, he/sheshould be countedin eitherthe 30 days und *ur living on the streetor in emergency stl'eetor sheltercategory,as appropriate.

I questions 1 - l5 for all participantswho left during the operatingyear (from 2c, columns and2). Theterm 1 Complete The or children caregivers. termchronically It not in persons aduits families. does include and participant single means beencontinuously who haseither condition with a disabling individual homeless personmeans unaccompanied an homeless To in of four (4) episodes homelessnessthe pastthree(3) years. be considered for homeless a yearor moreOR hashadat least (i.e.not transitional during housing) shelter or musthavebeenon the streets in an emergency homeless person a chronically dtays. these year, the participants leftduring opelating howmany who at of and 11. Amount Source MonthlyIncome Entryandat Exit,Of those

place monthlyircome the levelandeach of levelandwith eachsource income?Also,please monthlyincome participants wereat each A of in chart.The number participants Chart andB of persons thesecond column each in homeless for income chronically source,of be should thesame.
All Chronic All Chronic

a. b.

A. MonthlyIncome at Entrv No income


bl -

iii'ii: iitt*.i'
a.

At Sources EntrY C. Income Security Income(SSI Supplemental (SSDI) Disabiliry Income Security Social Security Social
u.
I

50

$ 15
q?5

$250

- $500 $ 50 - $1, 000

GeneralPublic Assistance

t
g

$1500 $1001$2000 $150i+ $2001

l.

(TANF) Aid Temporary to NeedyFamilies (SCHIP) Program HealthInsurance Children's State Benefits Veterans Income Employment Benefits Unemployment
Veterans Health Care Medicaid Food Stamps

h.

h.

J
t,

m,.
n

Other (pleasespeciS)

Resources No Financial

10

HUD-40118

AII B. Monthly Income at Exit


d,

Chronic at D. IncomeSoulces Exit


i:

All
lri\:t:iilitj:i

Chronic

No income
$l- ) U

a,

b.
d.

b. c. d.

(SSI) Income Security Supplemental (SSDI) DisabilityIncome Securiry Social Security Social
GenelalPublic Assistance TemporaryAid to Needy Families (TANF)

$1s $250 szs- $s00


$50 - $1, 00 0

f
g

$r001$r500 $r50r$2000
+ $2001

I
b.

(SCHIP) Insut'ance Program Health Children's Siate Benefits Veterans


EmploymentIncome

n,
I

Benefits Unemployment
VeteransHealth Care Medicaid

J
t,

I
n.

FoodStamps (please specify) Other


No FinancialResources

Explanatory Notes: (i.e.,on theprogran entered program the on income thedayhe/she monthly to at Table A: Monthlyincome entryrefers theparticipant's entering program income the or received received before not on as to dateor asclose possible thatday). You should rgpoft income entry stay. duringthe program exit left on monthlyincome thedayhe/she the program(i.e.,on theprogram date Table B: Monthly incomeat exit refersto the participant's the stay. during program received on to or ascloseaspossible thatday). You shouldnot repol't income (i.e.,on theprogram entered program the sources ofincomeon thedayhe/she at to Table C: Incomesources entryrefels theparticipant's before entering program income the or ofincomereceived on to entrydateor ascloseaspossible thatday). You shouldnot report sources in n, entryshouldbe reported category No Financial with no incomeat thetime of program stay. Participants receivedduling the program Resources, (i.e.,on theplogram date left exit on sources income thedayhe/she theprogram of to sources exit refers the participant's at Table D: Income stay.Participants no with received duringtheprogram ofincome possible thatday). You shouldnot reporton sources to or ascloseas Resources. in n, exit incomeat the time of program shouldbe reported category No Financial for year(from2c,columns and2), how manywereintheproject thefollowing I who 12a.Of thoseparticipants left dulingthe operating year persons lg.fiduringtheoperating in thesecond who homeless place lengthof stayfor chronically the lengths time? Also,please of column. All
Less than I month

Chronic

b.
c.
u-

f. h.

I to 2 months 3 - 6 months 7 months 12months 13months 24 months 25m ont hs -3 v e a rs 4v ear s - 5v e a rs 6y ear s - T y e a rs
8 veals - 10 vears Over l0 vears

Notes: Explanatory exit program entrydate program date.Ifthe participant only one and has ofstay usingtheparticipant's length eachparticipant's Compute entry datefrom theprogram date.Ifthe exit the year, lengthof stayby subtracting program calcuiate program exit dateduringtheoperating program (by subtracting year, of the stay the duringthe operating calculate length stayfor each exit participant multipleprograrn dates has to lengthof stay,Each stay)andaddthemtogether producea cumulative programenfiy datefi'omtheprogramexit datefor sachprogram

11

HUD-401 I8

participantsin the first column ("All") should with only one rengthof siay category. The total number of parricipantshould be associated equd ine numberof participantsin question2c, columns 1 and 2' (from 2d, columns I and 2), how long 12b. Length of Stay in Frograrn. For those parlicipantswho did not leave during the operatingyear hqverhewheen in the p-roject?Also, pieaseplacethe length of stay for chronically homelessFrs0ns who did nat leave during the operatingyear in the second column'

All
b. c. d. f. Less than I month I to 2 months

Chronic

3 - 6 months 7 months 12 months l3 months 24 months 2 5mo nth s-3 ye ar s

4 I

4y ear s - 5y ea rs 6y ear s - T y ea rs
8 years- l0 years
I.

Over 10vears

E xp l a n a torNot es : y year. To calculate program entry dateandthe last day of theoperating participant'slengthof stayusingthe participant's each Compute year, Eachparticipant be with should associated onlyone entrydatefrom thelastdayofthe operatng the lengthofstay,subtract program of in 2d, equalthenumber participants question columnC'Alf ) should in of category. The totalnumber participants thefir'st of length stay I columns and2. year(from2c,columns and2), how many I left duringthe opelating participants lg$ theproject who for 13. Reasons Leaving. Of those Thetotalnumberofpafticipants Ifaparticipantleftformultiplercasons,includeg4futheprimaryrcsson. forthefollowingreasons? place primary the I 2c, in the of in thefirst columnC'All") shouldequal number participants question columns and2. Also,please yearin the second column. personswho theproject duringthe operating left for reason chronicallyhomeless All
a. b.

Chronic

program Left for a housingopportunitybeforecompleting program Completed


Non-payment of renVoccupancy charge Non-compliancewith project

of / Climinalactivity/ destruction property violence Reached maximumtime allowedin project couldnot be met by project Needs with Disagreement rules/persons
Death

g. h.

j.
t,

specify) Other(please Unknown/disappeared

H UD - 4 0 I1 8
'L

14. Destination.ffiduringtheoperatingy.]G*l.,*lum11lyd2),howmanyleftforthefoi1owing year in lhe second personswholeft dudng the operating destination? Also, pleaseplacethe desti[iion ofchronically ho*reless column.

All

Chronic

PERMANENT (a-h)
b,

(no or house apartment subsidy) Rental Housing Public 8 Section PlusCare Shelter or house apartment HOME subsidized house apadment or Othersubsidized
Homeownership Moved in with family or fliends persons Transitionalhousing for homeless Moved in with family or friends Psychiatrichospital

d,

f. h. TRANSITIONAL (q) INSTITUTION (k-m)


L

j
K.

facility or alcohol otherdrugtreatment Inpatient m. EMERGENCY SHELTER(N) OTHER (o-q)


o.
Y'

Jail/prison shelter Emergency housing Othersupportive (e.g. habitation street) for not Places meant human specify)Death Other(please Unknown

q.

UNKNOWN

r,

ExplanatoryNotes: combine categories provided. response The usingthecategories the uponleaving program destination eachparticipant's IaenUry etc.). (e'g.,permanent, transitional, ,,destination" etc.) pubiichousing, homeownership, and"tenure" house apartment, or ie.g,,iental before categories sureto look at all of the response and response, be the and both destination tenuri to determine mostappropriate Consider category, response of provides briefdescription each a The makinga selection. tablebelow is categoryin eitherthe first columnof the tableor in both columnsif theparticipant undereachdestination EntertJrenumberof par-ticipants column in of The per be should recorded participant. totalnumber participanb thefltrst for reason leaving Only one homeless. chronically I 2c, in of (nRtf') stroutO equal number participants question columns and2. the Tenure Pemanent
Destination Rental house or apaftment (no subsidv) Description

a.
h

or withoutanysubsidy. to is Participant moving anapartment house unit. to is Participant movinA a publichousing as (formerly known a voucher choice will Participant usea housing to 8 Section voucher) rent a houseor apartment. PlusCare by to is Participant moving a unit funded the Shelter (e.s.. 8 TBA, SRA,PRA, Section SRO). Drosram provided the by assistance to is Participant moving a unit with rental (tenant-based pro.iect-based assistance). or HOME Drogram program other than by to is Participant moving a unit subsidized some (formerly 8), program Section voucher choice housing publichousing, PlusCare, HOME. or Shelter
Participantis moving to a unit that he/shehas purchased.

housins Public 8 Section PlusCare Shelter or house HOMEsubsidized


aDartmenl

o.

f.

houseor apat'tment Other subsidized

Homeownership Moved in with family ol friends

Transitional

for housing homeless Transitional people


J.

Movedin with familyor friends Psvchiatric hospital

Instifution

l,

andexpects livethere to is Participant movingin with family or friends for 90 davsor more. housing by is Parlicipant movinginto a unit funded a transitional funded through (e.g,, housing people transitional program homeless for Program). Housing the Supportive to and is Participant movingin with family or friends expects livethere less than90 davs. hospital. is Participant movinsto a psychiatric HUD- 401t 8

IJ

Tenure

L
111

Destination inpatientalcoholol otherdrug treatment facilitY

. . - - . Description . is Participant movingto u@ent

. ..

facility'

Emergency Shelter
Othet'

n,
o.

Jail/Prison shelter EmergencY


Other supportive housing

is Participant movingto a.iailor prison'. , - . people' for ts P"ttictpant *..rtttg t. uni*.tgenty shelter homeless
rrur l urrvrP v rrg P arti ci pant l s movl ng l nto suppol l l ve Il ousl rtg uraLuuq)

(a-h) categories andis nottransitional housing to anyofthe permanent 8 (i), people suc! asSection 1t housi# for housins homeless
P"t1rclpa"t ts t"ovlng to a place not meant for human habitation, such building. as a car, park, sidewalk,or abandoned to P"tti.tp*t it toving to a place that doesnot correspond any 0f the above(a-P)' catesories

n v'

q. Unknown
f

not Places meantfor human habitation sPecifY) Other(please


Unknown

where about unsurg if be should used youare c.t.gory rrrp"nse Thts

and the participantis moving or if the participanthas disappeared there is no way to find out where he/sheis. -

*HIJD encouragesprograms to limit the use ofthe "Other Supporfive Housing" APR response category. Programs should report (a) through (h) or in categories (i) through (i), respectively' destinations to housing that are perrtanent or rransitiona[ in APR categories be reported in category (n)' Exits to emergencyshelters should year (from 2, columns 1 and 2), how many receivedthe 15. Supportive Services. Of those participantswho lgft during the operating placethe supportiveservicesreceivedforchronically following supportiveservicesduring their time in the proleitt Also, please -in and all yiar the secondcolumn. Participantsmay have receivedmultiple services homelessparticipantswho left dur.ingthe operating table. servicesshould be reported in the

AII
4.

Chronic

b.
u,

Outreach management Case management) of Life skills(outside case set'vices Alcoholor drugabuse services Mentalhealth services HIV/AIDS-reIated Otherhealthcareservices Education placement Housing assistance Employment
Child care

e.
h

j
t.

Transportation
Legal Other'(pleasesPecifY)

1A

H UD - 4 0 1 1 8

Technical year(fromyourappiication, for objectives thisoperating list 16, oy:rallproeram Goals Underobjectives, you| measurable the in your progfess meeting objectives describe iistedbelow. underProgless, or Submission, ApR) for eachof thethreegoals year' for year.'s objectives thenextoperating the specify measul'able Objectives, Next Oper.ating Under
ResidentialStabilitY

^.

Attachrnent f 6 objectives:See

Progress:

Year'sObjectives: Next Operating

b.

IncreasedSkills or Income

See objectives: Attachment 16


Progress:

Year'sObjectives: Next Operating

c.

Greater Self-determination

See Objectives: Attachment 16


Progress:

Year'sObjectives: Next Operating

proiects do 17c. answer (,SflP-,S^9O 17b. answer SRorecipients recipients 17a. answer S+C 17. Beds. SHprecipients lrot complete this questiorc)
a. Effort'? Level' andunder'New under'Current forlftrsproject apploved in wereincluded theapplication SHp. How manybeds New Effort bedswereactuallyin placeat the endof the operatingyeat? How manyof these

New Effort in Place New Effort CulrentLevel of Beds: Number year? fundsat the endof theoperating with anddwellingunitswerebeingassisted project b. S+C. How manybeds and members, caregivers.) otherfamily for (Include beds all participants, of Number Beds: of Number DwellingUnits: c. 6 6

year? at SRO. How manydwellingunitswerebeingassisted theendof the operating persons qualifyfor assistance.) who (Include by unitsoctupied "in place"non-homeless Numbelof DwellingUnits:

l5

HUD-401l8

Part II: Financialtrnforcxration


Services, lB. Supportive was services spentduring (SHP), to information HUD on how SHPfundingfor supportive Housine this exhibitplovides For Supportive "Other"' under HMIS costs services. Include supportive on fundingspent these of the the operatingyear. Enter amount SFIP from all services plus Care(S+C), Speciffthe valueof supportive requirement. match services the this exhibittracks supportive For Shelter keep should persons received during the operatingyear. $+C grantees as thatcanbe counted matchthatall homeless sources services.) and amount, fypeof suppottive source, on documentation file, including personsduring the received homeless by services of to information HUD on thevalue suppor[ive thisexhibitprovides 8 For Section SRO. year. operating

Services Supportive
Outreach b.
Case management

Dollars

$94,940.94

of Life skills (outside casemanagement)


u.

Alcohol and drug abuseservices

$5,552.88 $6,127.05

Mentalhealthservices
I.
g

services A,IDS-related Otherhealthcareservices Education placement Housing assistance Employment


Child care

h.
L
J'

l. m,

Transpottation Legal

n.
o,

Asset Management (please speqifu) Other


TOT,AL (Sumof a thlough n)

$9,930.00 $ 11 1 , 5 5 0 . 9 0

of amount matchprovidedto datefor the Cumulative Plus CareProgramunder this gt4!t Shelter

t6

HUD.4OI L8

Operafing Costs,H[&S Activities and Administration 19. Supportive Housing Frograrn: Leasing,Supportive Serviees, year.Forexpansion each operating charts these mustcomplete Program Houiing Supportive receiving fundiig under.the All gLanGis for and facility,only thepeople expenditures theadditional homeless of projects: If SHPgrantfundsarefor the expansion a pr+existing to of usd Documentation resources is not required be or as expansion be included, in the originalapplication anygrantamendments. may any made inspection HUD andAuditors.Do not include expenditures by with this report shouldbe kepton frlefor possible submitted but befolethe SHPgrantwasexecuted. year Summaryof ExpendituresEnterthe amount SHPgrantfunds of match expended dulingtheoperating fol each activity. andcash be services totalshould thesame theSHPsupportive as This tableshould addup bothhorizontally vertically.The SHPsupportive and

Costs Operating HMIS Activities Administration

maynotbeshownasanoperatingexpense Note: Paymentsofprhcipalandinterestonanyloanormortgage Sourcesof Cash Match. Enter the sourcesof cashidentified in the Cash Match column, above,in the following categories,Use additional sheets,as necessary.

Amount
a.

Grantee/project sponsor cash (please Local government specif,)

b,

government (please State specify)

d.

government (please Federal specify) Community BIock Grant(CDBG) Development

(please Foundations specify)

l.

(please Privatecashresources specif)

Occupancy charge fees /


Total

T7

HUD-4OI I8

20. supportive Housing Pnogram: Acquisition, Rehabilitation' and New construction in these charts theyearoneAPR mustcomplete or r'ehabiliiation, newconstluction SHpfundsfor acquisition, that All grantees received of matchthe amount SHPfunds to at leastequally cash enough has to onty. this exhibit will demonstrate HUD that the gl'antee contributed is to fundswereprovided not required be submitted that Documentation matching or rehabilitation, new construction. spent acquisition, for inspection HUD andAuditors. by be with thisrenortbut should kepton file for possible
Summary of Expenditures. Enter the amount of SHP grant funds and cashmatch expendedduring the operatingyear for eachactivity.

SHPFunds
a.

Cash Match

Total Expenditules

Acquisition Rehabilitation
New construction

b.

A u.

Total

of Cash Match, Enter the sources cashidentified in the Cash Match column, above,in the following categories. Use additional sheets,as necessaly.

Amount
B

Granteeiproject sponsor cash Local government(pleasespecify)

b.

(please government specify) State

d.

Federal government(pleasespecify)

Development BlockGrant(CDBG) Community

(please specify) Foundations

f.

(please specify) Private cash resources

c.

Occupancycharge/fees

Total

t8

HUD-40r 18

GNT'Y ACTTVTTTES FAR FTMES


[Iousing(SHP) EIMISActivities 2 1. For Supportive year.Enter during the operating was seLvices spent fundingfor supportive to information HUD on how SHP-HMIS This exhibitprovides activities. on fundingspent these theamount SHP-HIr4IS of

HMIS Activities Ortly Central Server(s) Personal Computers and Printers Networking

Dollars

Security Subtotal

w ' . . . ' . . ' . .r.''....'


/ Software UserLicensing SoftwareInstallation
Support and Maintenance

Tools Software Supporting Subtotal Training by Third Parties Hosting/ TechnicalServices Customization Programming: Interface System Programming:
Programmin g: D ata Conversion

and SecurityAssessment SetuP (lnterne! Access) On-line'Connectivity Facilitation and Disaster Recovery Subtotal :' : '":':' ' ;fi.:r t:' tl:lr ::';r ;1;,-;:' 'i ;1, .i1;, " F ei ii i.nelt:.'''
Project Management / Coordination

ir .L'1':.,. ' : ,

:.'.

'r 'i .';,,, : - ..::' "'

'

DataAnalysis Programming
Technical Assistanceand Training

AdministrativeSupportStaff
Subtotal

; i'', o r S c I S-pa' earid,' pe'a/ioi rs,',: r, -=trfr Costs Operational


Total SpaceCosts

t9

r HUD-40l8

Describeany problems andlor changesimplemented during the operatingyear.

and Recommendations Technical Assistance Based on your experience during the last year, are there any areasin whidr you need technical advice or assistance? Ifso, pleasedescribe'

20

HUD-40118

Report Fersons Served Worksheet - FIUD Annual Progress

PersonalInformation (PPI) on this form is done with the knowledgeor consentdthe clients. The Collection of the Protected PPI is only used for the following purpose: Program in Report(APR) for the Continuum of Care (CoC) HomelessAssistance Accuratecompletionof the.Annual Progress which the client is enrolled. This worksheet optional is intended helpyou collect is to information and needed complete AnnualProgress to the Report. Instructions and Codes follow.Do not submitthis worksheet IIUD. to
Nurnber Monthsin of (calculate) Project l2a Numberof Months in Project -Participant did notleave (calculate) I2b (i Non-Homeless Only) ( Y/N ) 4

Persons Served Worksheet (continued) (PPI)on thisform is donewith theknowledgeor Collection theProtected of Personal Information consent theclients.The of PPI is only used the followingpurpose: for Accurate (APR)for theContinuum Care(CoC)Homeless completion the AnnualProgress of Report of Assistance Program in whichthe clientis enrolled.
Do not submitthisworksheetto HUD
No. Veterans (YN) Status 6a Chronically Homeless (YN) 6b Ethnicity 7 Race (code) 8
SpecialNeeds (code) 9a

Special Needs (code) 9b

Prior Living Situation (code ) l0

Monthly Income At Project Entry lla

MonthlyIncorne At Project Exit l tb

/l

HUD-4OI I8

22

HUD-4OI I8

Persons Served Worksheet (continued) or of (PPI)on thisform is donewith theknowledge consent theclients.The Information Personal of Coliection theProtected for PPIis only used thefollowingpurpose: Program in Assistance of Report(APR)for theContinuum Care(CoC)Homeless of Accurate completion theAnnualProgress whichtheclientis enroiled.
Do not submit this worksheet to F{UD Reason Leaving for Program(code)
IJ

lnstructions and Codesfor PersonsServedWorksheet

Th e u se of t his wor k s h e e ti s o p ti o n a l . It w a s d e s i gned to h e l p y ou c ollec t info rm a ti o no n p a rti c i p a n tsn e e ded to co m plet et he A nnu a l P ro g re s sR e p o rt, If th e wo r-ks heet updat eda s p a rti c i p a n tsm o v e i n a n d m ove is o u t o f y our pr ojec t ,mo s t o f th e i n fo rm a ti o n re q u i r ed fo r co m plet ionwill be c o n ta i n e di n th e w o rk s h e e t . D o n o t su bm it t his wor k s h e e t i th th e AP R . w Fo r p ro jec t st hat s er v efa m i l i e s , H U D o n l y re q u i re s re p o rti ng on t he numb e ro fc h i l d l e n s e rv e d ,a n d th e a g e a nd genderof t he s ec h i l d re n , O n l y n a m e , re l a ti o ns hip,dat e of b i rth , a n d a g e o n th e w o rk s h e et
ZJ

need to be compl etedfor chi l dren. A ssi gn the adult s a numbgr,but not each fami l y member. U se thi s num ber to transfel to the other pagesof the w orksheet . B egi nni ng w i th numbe 4, the numbersi n the colum ns r refer to the questi onson the A P R form. If any questi onsare answ el edw i th " Other," pl easeent er t he speci fi c " Other" answ erfor i ncl usi on i n the A PR. P arti ci pant N umber. Thi s col umn al l ow s you to ei ther number parti ci pantsconsecuti vel y t o or assi gna casenumber. One numbershoul d be assi gned each adul t. to

HUD-40il8

Nam e . N am es of per s onw i l l n o t b e re p o rte dto s F I U D. Th e us e of nam esis fo l y o u r re c o rd k e e p i n g c ont,e n i e nc e. Rela ti o n ship. E nt eLt he a p p ro p l i a tere l a ti o n s h i p , E xa mp l e sinc lude: S elf , H e a d o f h o u s e h o l d ,Sp o u s e , ch ild. Entry D a te . E nt el dat e p a rti c i p a n te n te l e dth e pr o j e ct, Us ually t his will b e th e d a te o f a c tu a l phy si ca l mov e- in f or a ho u s i n g p ro j e c t. Exit Da te . E nt er dat e pa rti c i p a n tl e ft th e p ro j e c t. U s u a l l y th i s will be t he da te th e p a rti c i p a n t physi ca l l y m ov ed out f or a h o u s i n g p ro j e c t. D o n o t incl u d e a par t ic ipantwho te m p o ra ri l yl e ft th e p ro j e c t and i s e xp ec t edt o r et ur n i n l e s sth a n 9 0 d a y s (e .g ., hos p i ta li za t ion) . 4. i In co me- eligible Non-h o me l e s s n SR O . T h e SR O p ro g ra m allows as s ista n c e u n i ts o c c u p i e db y to Se cti on 8 inc om e- eli g i b l ep e rs o n sre s i d i n g a t th e SR O p rior t o r ehabili ta ti o n .F o r SR O p ro j e c ts o n l y, i ndic at e whet he rth e p a rti c i p a n ti s a n p i n co me - eligible,non- h o me l e s s e rs o n(Y) o r n o t (N ). SHP and S + C pr o j e c tss h o u l d s k i p th i s i te m .

a. Mental i l l ness b. A l cohol abuse c. D rug abuse d. H IV /A ID S and rel ated di seases e. D evel opmental sabi l i ty di f. P hysi caldi sabi l i ti es g. D omesti cvi ol ence h, Other (pl easespeci fy) 9b. E nter the number of parti ci pantsw i th a di sabilit y 10. P ri or Li vi ng S i tuati on. E nter the l etter that b est w descri bes hel e the parti ci pant sl ept i n the w e ek pri or to enteri ngthe proj ect. D o not doubl e count, a, N on-housi ng(street,park, car, bus stati on,etc.) shel ter b. E mergency c. Transi ti onalhousi ng for hornel ess persons faci l i ty* d. P sychi atri c e. S ubstance abusetreatmentfaci l i tv* f. H ospi tal * g. Jai l /pri son* h, D omesti cvi ol ence si tuati on i . Li vi ng w i th rel ati ves/fl i ends j . R entalhousi ng k. Other (pl easespeci fy) xl f a parti ci pantcamefrom an i nsti tuti on but w as there l essthan 30 days and w as l i vi ng on the shel ter before enteri ng the streetor i n an emergency faci l i ty, he/sheshoul d be counted i n ei ther the st r eet or shel tercategory,as appropri ate. Instructi on C odes for P ersons S erved W orksheet (conti nued) I I a.GrossMonthl y [ncome at P roj ect E ntry. E nter the amount of gross monthl y i ncomethe parti ci panti s recei vi ng at entry i nto the proj e ct . I I b.GrossMonthl y Income at P roj ect E xi t. E nter the grossmonthl y i ncome the parti ci panti s recei vi ngw hen exi ti ng the proj ect. l l c,Income S ourcesR ecei ved at P roj ect E ntry, E nter al l types of assi stance parti ci panti s the recei vi ngat entry to the proj ect. a. S uppl emental ecuri ty Income (S S I) S (S b. S oci al S ecuri ty D i sabi l i ty Insurance S D I) c. S oci al S ecuri ty d. GeneralP ubl i c A ssi stance e. TemporaryA i d N eedy Fami l i es (TA N F) HealthInsurance Program (SCHIP) f. State Childlen's g. V eteransbenefi ts h. E mpl oymenti ncome benefi ts i . U nempl oyment j , V eteransH eal th C are k. Medi cai d l . Food S tamps m. Other (pl easespeci fy) n. N o Fi nanci al R esources
1A

5a. Da te of B ir t h. E nt er d a te o f b i rth i n c l u d i n s mo n th , day , and y ear, 5b. Ag e . E nt er age at en try . 5c . Ge n d e r . E nt er appr o p ri a tel e tte r fo r g e n d e r. M-Ma le F - F em ale. 6a. Ve te ra ns S t at us . I nd i c a te i fth e p a rti c i p a n t i s a ve te ran. P leas e not e : A v e te ra ni s a n y o n ew h o h a s e ver been on ac ' ti v em i l i ta ry d u ty s ta tu sfo r the United States. 6b. Ch ro n ic ally hom eles sp e rs o n . In d i c a teth e n u mb er of par t ic ipan tsth a t a re c h ro n i c a l l y h o me l es s . 7. Eth n i c it y . E nt er app ro p ri a tel e tte r fo r e th n i c g ro u p . a . H i spanic or Lat ino b . No n - His panic or N o n -L a ti n o Ra ce . E nt er appr opr i a tel e tte r fo r ra c e . a . Ame r ic an I ndian or Al a s k a nN a ti v e b . Asi a n c. Bl a c k or A f r ic an- A m e ri c a n d . Na ti v e Hawaiian o r Oth e r Pa c i fi c Is l a n d e r e . Wh i t e N f, Amer ic an I ndian/ A l a s k a n a ti v e & Wh i te g . Asi a n & W hit e h . Bl a c k / A f r ic an A m e ri c a n & W h i te N i . Ame r ic an I ndian/ A l a s k a n a ti v e & B l a c k / A f r ic an A m e ri c a n j . Oth er M ult i- Rac ial

8.

9a. Sp e ci a l Needs . E nt e r th e l e tte r(s )fo r th e ca te g oly ( ies )t hat des c ri b eth e p a rti c i p a n t' s d i sa b i lit y ( ies ) . ( Y ou m a y d o u b l e c o u n t).

HUD-40118

1l d .Inc om e S our c esR e c e i v e da t Pro j e c t E x i t. En t er all t y pes of i n c o me th e p a rti c i p a n t i s re c eiv ingat pr oje c t e x i t. (U s e c o d e sa s i n 1 1 c.)
i 2a Len gth in Sta y in Pr ogr am . Calc ulat ed it em . (S ee Entry Da te and Ex it Dat e abov e. )

1 2 b . L engt h of S t ay i n P ro g ra m . (Pa rti c i p a n td i d n ot leav e dur ing th e o p e ra ti n E y e a r.H o w l o n g h av e t hey beenin th e p ro j e c t? ) 1 3 . Reas onf or Leavi n g P ro j e c t. En te r th e p ri mary re as onwhy t he pa rti c i p a n tIe ft th e p ro j e c t. (C om plet eonly f o r p a rti c i p a n tsw h o l e ft th e p rojec t and ar e no t e x p e c te dto re tu rn w i th i n 90 days. a . L ef t f or a hous i n g o p p o rtu n i ty b e fo re co m plet ingt he pr o g ra m b . Com plet edpr o g ra m c o c. Non- pay m ent f re n t/o c c u p a n c y h a rg e d . Non- c om plian c e i th p ro j e c t w o e . C r im inal ac t iv i ty /d e s tl u c ti o n f p ro p e rty / vi o lenc 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 eeds c ould no t b e m e t b y p ro j e c t w h . Dis agr eem ent i th ru l e s /p e rs o n s i . Deat h j . Ot her ( pleas esp e c i fy ) k. Unk nown/ dis a p p e a re d

5. S upporti ve S ervi ces. E nter al l typesof duling supporti veservi cesthe pal ti ci pantrecei ved the ti me i n the proj ect. a. Outreach b. C ase management c. Li fe ski l l s (outsi deof casemanage m ent ) d. A l cohol or drug abuseservi ces e. Mental heal th servi ces f. H IV /A ID S -rel ated servi 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 [. Transportation m, Legal n. Other(please specif,)

1 4 . Des t inat ion. E nte l th e d e s ti n a ti o no fth o s e l e av ing t he pr ojec t. Pe r m anent r a, Rent al hou s eo r a p a rtme n t(n o s u b s i d y ) b. P ublic F lo u s i n g c . S ec t ion8 d. S helt erP lu s C a re e, HO M E s u b s i d i z e dh o u s eo t' a p a rtme n t f . O t her s ubs i d i z e dh o u s e o r a p a rtme n t g. Hom eown e rs h i p h. M ov ed in w i th fa mi l y o r fri e n d s Tra ns it ional: i. T r ans it iona lh o u s i n g fo r h o me l e s sp e rs ons j. M ov ed in w i th fa m i ty o r fri e n d s In s t it ut ion: k . P s y c hiat r i ch o s p i ta l . l. I npat iental c o h o l o r d ru g tre a tme n tfa c i li ty m . J aillpr is on Em er genc y : r n. E m er genc y h e l te s Oth er : o. O t her s upp o rti v eh o u s i n g . p. P lac esnot me a n t fo r h u ma n h a b i i a ti o n ( e. g. , s t r eet ) q. O t her ( ple a s es p e c i fy ) U nk nown: r . Unk nown z) HUD- 40118

Ftrazel Betsey Apartments(Studio) Reporting -7/31107 Period: 811106

cA O 1 c s 0 1 0 3 8
15. OverallFrogramGoals,

Residential Stability: Objective: housing atsixmonths. At least 80%of participants remain will for (6 PlusCarehousing Progress: 100% of 6) of participants remained Shelter in Exceeded. folsix months. forsix months. in Next Operating will Year'sObjective: At leastB0%of parlicipants remain housing Objective: will foroneyear. At leastT}Yoparticipants remain housing in Progress: 100%(6 of 6) of participants remained Shelter in PIusCarehousing foroneyear. Exceeded. participants remain housing in foroneyear. Next Operating 70%o wili Year'sObjective: At least Increased Skillsor Income: year. employment duringthe operating wiil Objective: At leastl0% of participants obtain/sustain year. obtained/sustained employment duringthe operating Exceeded. Progress: 33% (2 of 6) of participants will employmentduring of the Next Operating At least10Yo participants obtain/sustain Year'sObjective: year. operating 4A% fulftime (nottemporary) who obtainemployment, will obtain employment. Of those employment, obtained fulltime (nottemporary) Exceeded. who obtained 50%(1 of 2) of those employment. 40%will obtainfulltime (not temporary) Year'sObjective: Of thosewho obtainemployment, Next Operating employment. Objective: Progress: Greater Self-determination: in meetings. At least 35%will paffiicipate tenant Objective: in meetings. haveparticipated tenant l0A% 6 of 6) participants Exceeded. Progress: in meetings At least 35%will participate tenant Next Operating Year'sObjective: relationshipbuilding,literacy, and skillssuchassocialization, At least 75%wilLdevelop acquire skills and moneymanagement, artistic relationship and skillssuchassocialization, nA% (6 of 6) havedeveloped acquired Exceeded. Progress: are and building, literacy,moneymanagement, artisticskills. Tenantmeetings set-upsothatthe withinthe skillsandlearnhow to buildrelationships socialization can tenants leamappropriate manager helps tenants the as building'scommunity well asoutside building,Theprogram all to skillsin skillsandencourages thetenants buildtheirartistic moneymanagement develop differentways. skillssuchassocialization, relationshipbuilding, and Year'sObjective: At least75%will develop acquire Next Operating skills. and moneymaragement, artistic literacy, Objective:

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