(exp.11/30/2009) No.

OMB Approval 2506-0145

U. S. Department of Housing and Urban Development Office of Community Planning and Develooment

GOPV

Annual Frogress Report (APR)

for Supportive HousingProgram ShelterPlusCare and Section ModerateRehabilitation 8 for SingleRoomOccupancy Dwellings(SRO)Program

ofinformation estimated average hoursperresponse, Public reportingburdenfor thiscollection is to 33 including thetimeforreviewing insffuctions, gathering maintaining dataneeded, completing reviewingthe collection information. Thisagency existingdatasources, and searching the and and of may not conductor sponsor, a person not required respond a collection information is to and to, of unless that collection displays valid OMB control a number. HUD-40118

General Instructions and purpose. The AnnualProgress Report(APR) is a repoting tool thatI{UD usesto fiack programprogress funding. assistance process homeless for competitive and accompllqhments informtheDeparlrnent's
grants must submit 2 APR'S to HfID within 90 davs after Filing Reli,iiiriments. Recipientsof lftlD's homelessassistance copy of the report must be submittedto the Community Planning and Development the end ofeach operatins vear. One (CPD) Division Director in the local HUD Field Office responsiblefor managing the grant. The other copy must be submrtted to HUD Headquarters,Department of Housing and Urban Development,Atfir: APR Data Editor, Room 7262, 451 7o Street, SW, Washington, DC. 20410. Failure to submit an APR will delay receiving grant funds and may result in a determiaation of lack of capacity for future firnding. An APR must be submitted for each operating year in which HUD funding is provided. Granteesthat received SHP funding for new construction, acquisifion, or rehabilitation are required to operatetheir facilities for 20 years. They must submit an APR 90 days after the end of the first operating year and every year throughout the 20 years. A separatereport must be submifted for each HUD grant received. For ShelterPlus Care (S+C), a separateAPR must be submitted for each S+C component. For those granteesreceiving an extension, a separatereport covering that period must be submrtted(seeExtension below). Recordkeeping. Granteesmust collect and maintain information on eachparlicipant in order to complete an APR. Optional worlsheets are attached. The worksheetsmay be used to record information manually or to design a computerized systemto store and tabulate the information. The worksheetsshould not be submittedto HUD with the APR. Organization of the Report. The APR is organized in the following manner: Part I: Project Progress. This portion of the report describesthe progressin moving homelesspersonsto self-sufficiency, documenting servicesreceived, listing project goals, and accountingfor beds/units. Part II: Financial Information. and SRO. This portion of the report is completedby all granteesreceivilg funding under SHP, S*C,
i! .r

Final Assembly of Report. After the entire report is assembled, number every page sequentially. Mark any questionsthat do not apply to your program with'N/A" for not applicable. (See Special Instructions for SSO Projects below.) Definitions of Client/Ilousehold Types. Each client/householdtype is dehned below. Note that a ciient's clienthousehold type should be based on the client's age and/or household composition at theprogram entry date closestto the start of the operafitxgyear. Families - A family is a household composedof two or more related persons,at least one of who is a child accompanied by an adult or ajuvenile parent. Singles not in Families - Personsnot accompaniedby children, including pregnant women not accompaniedby other children and unaccompaniedyoutl, are singles not in families. When two adults or two unaccompaniedyouth present togetherfor services, eachpersonshouldbe countedin singlesnot in families.. Clients' householdstatusshouldbe determined basedon their household composition at the program enby date closest to the start of the operating year. This means that pregnant women expectedto give birth during their program stay should still be counted as singles not in families. Adults in Families - Within a family, an adult is any person 18 years of age or older, For the purposesof APR reporting, the determination of whether a person is an adult in family should be made based on their age and householdcomposition at the program entry date closest to the start of the operating year. Children in Families - Children in Families are definedas childrenunderthe age of 18 accompanied one or more by adults (parent, relative or guardian). Children in families also include both ajuvenile parent and the parent's child(ren). For the purposesof APR reporting, the determination of whether a person is a child in family should be made based on their age and household composition at the program entry date closestto the start of the operating year. For example, clients who are less than 18 years of age on the fust day of the operatingyear or at program enty (if they enteredduring the operating year) should be counted as children even if they turn 18 during the course of the operatingyeat.
HUD-401 8 t

persons in Families - Personsin families includes adults in families and children in families.

Other Key Definitions. The following terms are used in the APR. As indicated, in sonte cases,tetms are applied differently dependingon whether the funding is from SHP, S+C, or SRO. person as "an unaccompanied homelessindividual Chronically homelessperson - HIrD definesa chro rically homeless with a disabliag condition who has either been continuously homelessfor a year or more OR has had at least fow (4) chronicallyhomeless, personmust havebeen on a in episodes homelessness the past tbree(3) years." To be considered of the streetsor in an emergencyshelter (i.e., not in transitional housing) during thesestays. HUD's dehnilion of a chronically homelessperson is based on the following components: c Unaccompanied homelessindividual: an unaccompanied homeless individual has the samecharacteristics of a Single not in a Family (describedabove). . Disabling condition: seethe instructions under disabling condition (below) to determine whether a client is disabled. Did not leave the program - This term refers to clients who were in the program on the last day of the operatingyear. Disabling condition - HUD dehnesa disablingcondition as: (1) A disability as definedin Section223 of the Social Security Act; (2) a physical, mental, or emotional impairment which is (a) expectedto be of long-continued and indefinite duration, (b) substantially impedes an individual's ability to live independently,and (c) of such a nature that such abilify could be improved by more suitable housing conditions; (3) a developmental disability as defured in secfion 102 of the Developmental Disabilities Assistanceand Bill of Rights Ac! (4) the diseaseof acquired immunodeficiency syndrome or any conditions arising from the etiological agencyfor acquired immunodefrciency syrdrome; or (5) a diagnosable substanceabusedisorder. Entered the program - Entered the program refers to the frst day a client receives services. For a residential prograrq this date would representthe fust day of residencein the program's housing. For services,this date may representthe day of program effollment, the day a service was provided, or the fust date of a period of continuous parficipation in a service (e.g., daily, weekly, or monthly). For S+C and SRO prograrns,the program entry date is the date that the participant starts to receive rental assistance.For and S+C, servicesprovided prior to this point arc recognizedas necessaryfor outreach,/enrdllment are eligible to count as match. An Extension APR applies to SI{P and S+C granteesthat requestedand received an extension oftheir grant term from the HUD field office. The only difference between an APR for the extensionperiod and the regular APR (besidesthe amount of time covered) is the signaturepage. Granteesshould circle "yes" to indicate the APR is for an extension period and circle the operating year for which the report is an extension.For example, if the granteeis extending year 3, the granteeshould submit an APR as usual for year 3 and submit another APR for the extensionperiod, indicating the secondis an extension and also circling year 3 on the signaturepage. Grantee meansa direct recipient of the HUD award. Left the program - Left the program refers to the last day a client receives services. For a residential prograr4 this date would representthe last day of residencein the program's housing. For services,the exit date may representthe last day a service was provided or the last date of a period of continuous service. If a client leaves the program temporarily (e.g., for a hospitalizanon) but is expectedto return within 30 days, do not count that client as having left the program. and is not For S+C progranrs,the program exit date refers to the date the parficipant stopsreceiving rental assistance expectedto return to S+C assistedhousing. If the participant returns to S+C assistedhousing within 90 days, the person should not be consideredas exiting from the program. If the person returns to S+C assistedhousing after 90 days, that person is considereda new pafficipant. The worksheet is designedto captue this information. Match for S+C is the value of supporfive servicesreceived by participants in the S+C project which, in the aggregate, provided over the life of the project. For SHP, match is cash must at least equal the value of the S+C rental assistance HUD_40118 3

rehabilitation, new construction, operations used to provide the grantee,sportion ofacquisition, expenses.

and supportive services

developmentactivities for acquisition, Operating year - For SHp programs, the lust operating year begurs after after a copy of the cerrrfrcate of occupancy is sent to the local HUD rehabilitation, and new constnrclion are completi, rehabilitation' or new office, and when the frrst participant is acceptedinto the project. For projects wthout acquisition, when the granteeacceptsthe fust participant. For dedicatedHMIS projects' construction, the operating start date begins -when any eligible cost included in the approvedproject budget is incurred' For S+C (SRA, the operating year tegins pRA and TRA components),the frrst operating year begins on the date HUD signs the grant agreement. For S+C/SRO (HAP) Pa)rynents and for Sec. g SRo, the first operating year begins with the effective date of the Housing Assistance Contract. To deterrninewhich operating year to circle ol the APR cover page, begin counting from the initial grant operating start date and include renewal grants. For example,a project receiving an initial grant for three years and a renewal grant for two years would circle years 1, 2, and3 respectively on the APR cover sheetfor the rmtial grant and would circle 4 and 5 respectively for the renewal grant. For any future renewal grants, the granteewould begin by circling 6 on the APR cover sheet. participants - The term participant refers to Singles not in Families and Adults in Families as defined above. Participant does not include children or caregiverswho live with the adults assistec. project Sponsor means the organizationresponsible for carq.ing out the daily operation of the project, if the organization is an entity other than the grantee. should completeall questions, rams. SSO grantees ce Onl Su ial Inst .,rol"r, u written ugr""-grrt hut b.en reachedwith the field office concerning which questionscan be answeredusing estimates, or in rare instances,skipped. Below is an example of how information could be derived il a large, single-serviceSSO project: staff member could be assignedto collect information from the organizationshousing the participants. The A grantee/sponsor staff person would contact these individual organizationsto requestinformation regarding the persons in that facility that use the service. For parlicipants living on the street,the grantee/projectsponsormay provide estimates. Information could be collected for eachparficipant or for parlicipants receiving servicesat a point-in-time. If estimatesor point-in-time counts are used, the method used must be described in the APR and the documentationkept on file' grants, granteesoperating SSO projects are expectedto assistance As with all projects funded under HIID's homelessness complete ai apR questions rhatare applicable to them. Note that all projects have been awarded funds as a result of and responding to the piogram goals of assistinghomelesspersons obtain/remain in permanenthousing and increasetheir skills income. The APR documentstheir progressia meeting these goals' In some circumstancesfield offices and granteesmay sign a written agreementconcerning questionsthat can be answeredusing estimates,or in rare irstances, skipped. Seethe special instructions below for reporting on special types of projects, such as outreach only projects, projects providing servicesto children only, and kansportation, medical, dental, and other single, shortduration service projects. SSO programs are a third priority for local HMIS implementation, following emergencyshelters,transitional housing programs, grantees outreachprograms, and permanentsupportive housing programs. once SSo programs are included in the HMIS, SSo apn questionsusing their HMIS data. SSO granteesthat are not yet parhcipating in HMIS will need will be able to answer ai to collect data to answer the APR questionsusing the special instructions provided above' are Outreach Only Projects. Projects which are solely devoted to street outreachand connection to housing and services their contact with personson the street. It is sufficient for theseprojects to enter not required to track participants beyond for questions 5-9 are allowed, given that hformation on questionsl-10 (skippingquestionsi 1-13 and 17). Estimates parncipantsmay be reluctantto answerpersonalquestions'

HUD-40118

the appropriatenumber of people, providing basic Answering the questionswill demonsh ate thatthe granteeis serving of demonstralingthat homelesspersonsare being served, demonstratingthe types demographic irrforrnation for congress, housing parlicipants are connectedto, and the type of servicesthey are receivirg' is often tr{otline Frojects. Hotline sewices are similar to outreach only projeets, but contactbetween granteeand padicipant program nearly simultaneously. It is sufficient for theseprojects to answer of very short duration - people enter and leave the (skipping 17). questions1-5 (skipping4), 10, ar,ld74-19 for Projects Providing Services To Children Only. Projectsthat provide child care,after schoolcare,counsehng children, etc. make an important contribution toward moving a famrly out of homelessness.Wlule the main focus of the project is providing servicesto the chjldren, it is the adults who are reported on ia questions6- l 6 of the APR. Like all other proj ects, this type is also targeted toward getting the families into housing and increasingthe families' incomes. Granteesmay skip (except 17). shouldbe answered question9; all other questions provide a Transportation, Medical, Dental, and Other Single, Short-Duration Service Projects. Somegrantees single service of fairly short duration focused ONLY indirectly on assistinghomelesspersonsto obtain/remainin permanent housing and increasetheir skilis and incomes. It is sufficient for theseprojects to enter information on questions 1-10 and 14to 19 (question 17 may be skipped). However, with transportation services,it is unreasonable think that someonewould have to give their age, race, and ethnicity to a bus driver to get a ride a few blocks. For these services,provide a narrative, which gives the number of rides given during the operating year, and provides estimates on the above statisticsbased on the population that utilizes the service. For Safe Haven (SH) Proiects. Grantees should report on all participants served dwing the Special Instructions operating year. Note: this is a changefrom prior instructions where granteeswere instructed to report on the first 25 parficipants served.

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

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

HUD-4O1 18

. BY PA,GE TOBE CAMFLETED ALL GRANTEES TWIS

Grantee:

HUD Grantor ProjectNurnber:

Ciiy ond Counly of Scn Frqncisco

Project Sponsor:

cA01csoi047
Name: Project GLIDTCOMMtJNryHOUSE CECILWILLTAMS
Rcporti ng Period: (morttiiday/ycar)

HOUSING GLIDECOMMUNITY
year on) the OperatingYear: (Circle operating beingreported

D r D z x3 [+ n s Do Dr [e nq E lo D r i l r z [i s [i + fl rs Dto ntz ltr Dtc E zo

Indicateif extension: Indicateif renewal: I Y"s X No X Yes I No

from:7/01/2006to: 613012007

for Numbers this proiect: Grant Previous

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

SupportiveHousingProgram (SIf) f n

ShelrcrPlus Care(S+C) (TRA) RentalAssistance Tenanlbased (SRA) RentalAssistance Sponsor-based (PRA) Project-based Rental Assistance (SRO) Roomoccupancy Siagle

Section 8 ModerateRehabilitation n SingleRoomOccupancy (Sec.8 SRO)

f,

Transitional Housing D for Housing Homeless X Perrnanent n Persons with Disabilities tr SafeHaven
Innovative Supportive Housing Supportive ServicesOriiy HMIS

year) and served accomplishments operating this with number of Summaryof the project:(Oneor fwo scntences a description population, year, this project providedup to 22 unitsof permanenthousing to homelesssingle adults.All of the Duringthis operating participants sheltersand are livingwith two or more special needs relatedto mentalhealth, were from the streets or ernergency ab{use), and i or HIV/AIDS. Substance
Name & Title ofthe Personurlto can anslver qucstions about this report: Pamela Grayson-Holn'pn - Oflice Manager Phone: (include areacode) 4t5-674-6t47 Fax Number: (include areacode)

Address: 333 TaylorStreet CA SanFiancisco, 94102 pgraysOn @gl ide.org Adriress E-rnail

(4Ls)674-s537

I hereby certify that all the information stated herein is true and accurate.
Conviction resultin criminal andstatements. may false Warning: HUD will prosecute claims 1 0 1 0 l,0 1 2; 3l U. S . C. 37 2 9 ,3
Name & Title of AuthorizedGranteeOfficial:

ti cs.(18U .S .C .

StephenAdviento Program& GrantsAnalyst

Name and -fitle of Authorizcd Project SponsorOfficial:

Signature "W

Signature &

Director DeborahWhittle, Executive

X

H U D - 4 0 I1 8

(EXCPT HMTS) BY I. PAR.T TOBE COMPLETED ALL GRANTEES

ON SEESPECIALIT'{STRUCTIONS PAGE3 OF THEAPR' PLEASE GRANTEES, SSO Fart I: Froiect Frogress
1.
rcatl0n.
Number of SinglesNot in Families

projected Level of p".ro.r, to be served at a given point in time. (This informationcomesffom the most recentCoC
Numberof Adultsin Families Numberof Children in Families
Number of Families

a.

ProiectedLevel Personsto be served at a given point in time

22

2.

Persons Served during the operating year.

Numberof Singles in Not Families Number on the hrst day of the operating year Numberof Adultsin Families
Number of Children in Families Number of Families

19

b.

Number entering program during the operating year

3 2 20

year Numberwho left the programduringthe operating

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

Explanatory notes: See Deflnitions of Clienltlousehold Types in the General Instructions above to determine which clients should be counted as Singles Not in Families, Adults in Families, and Children in Families. Note that this table does not account for changesin client/household type that may occur during the course ofthe operating year. Instead, each client should be assigneda single client/household rype basedon the client's age and/or household composition at the program entry date closest to the start of the operating year. In this way, each client is counted only once in the table. Use the following graphic and explanations to determine who should be counted in rows a-d:

on Clienl program firstdayof in year,lefiduring the operating year count 2a and2c. in in on Clienl program frst day year of operating andlesl year: counl dayofoperaling in 2a and2d. F------+
H Clienl entered and left program before start of opgratingyeaI do not counl in queslion 2.

and Client eniered leff program during operating year count 2b and2c. in program entered during Clienl yBar operating andstillin program lastdayofyear on in count 2b and2d.

FiFt day ofthe year operating

Lasi day oflhe operating lEar

L,

Number on the first day of the operating year: This row includes all clients who enteredthe program before the first day of the operating year and did not leave the program until after the first day ofthe operating year. Number entering the program during the operating year: This row includes all clients who entered the program on or after the first day of the operating year, up to and including the last day of the operating year. For clients with multiple program entry dates, use the entry date closest to the start ofthe operating year. Do not count the ciient more than once even ifhe/she enteredthe program more than once during the operatingYear, Number who left during the operating year: This row includes all clients who left the program on or after the first day of the operating year, up to and inciuding the last day of the operating year. For clients with multiple progam exit dates,use the exit date 7 HUD-40118

b,

c.

during morethanonce the evenifhe/sheexited program Do year. not counttheclientmorethanonce to closest the endofthe operating
th a ^nar at;nn \/aDr

d.

year: Thisrow includes clients all who werein theprogram ofthe first as Number in the programon the lastday ofthe operating rlqvnf the nncrqrin .rear who entered o year year.Thenumber duringtheoperating duringtheoperating andwho did not leave of or year on based theresponses rows2athrough For to 2c. clientsor fanlliesin theprogram thelastdayofthe operating is calculated on or in of in each column,addthenumber clients fanrilies row 2a to thenumber clients families row 2b andsubtract number of or the of clients families rou,2c. Therefore, = 2a+ 2b * 2c. 2d or in

3.

Froject Capacity.
Number of SinglesNot in Families

Number of Aduitsin Families

:rii::ii.'ii ,ll;:,r!
I .. . . l:i:.,:,': -.:

Number of Chrldren in Families

Number of Families

a.

Number on the last day (fi'om 2d, columns I and 4) Number proposedin application(from 1a, columns 1 and 4) Capacity Rate (divide aby b'): %

20 22
91%

b. c.

..,

'
%

'.l

ExplanatoryNotes: Row b refers the mostrecent to CoCapplication whichtheprogram reporting. for is

4.

Non-homelesspersons. Th-isquestionis to be completedfor Section8 SRO projects.

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

5.

Age and Gender. Of those who entered the project during the operatingyear, how many people are in the foilowing age and gendercategories? SinglePersons(from 2ti. column 1
2

Age 62 and over

Male
4 I

Female

b.
c.
A

51-61 31-50 18-30 17andunder

62 and over

Personsin Families(from 2b. columns2 & 3)

f.

t,

51-61 31 - 50 l 8-30 t3-17 6-12 1-5 Under1

ExplanatoryNotes: Thisquestion refers onlyto Singles in Families Persons Families not and r.l,ho in entered program the duringthe operating year.Onlyclients who meetthese criteria be counted thistable. Thetotalnumber can in ofclientsreported underSingle Persons should equal the be to number reported question column1. Thetotalnumber clients in 2b, of reported under Persons Families in should equal thesumof be to columns and3 in question 2 2b. Answer questions6 - 10 only for participants who entered the proj ect during the operating year (from 2b, columns1 & Z). The term participant meansSinglesnot in Families and Adults in Famiiies. It doesnot ilclude children or caregivers.NOTE: The total for questions , I and 10 below shouldbe the same;respondto eachof those questions all participants.Someof for ,7 the questions listed throughout the APR will be asking information for individuals who are chronically homeless.

HUD-40118

who haseverbeenon activemilitary duty status is 6a, Veteransstatus.A veteran anyone

How many participants were veterans? individual with a disabling condition who has eitherbeencontinuously homeless 6b. Chronically homelessperson. An unaccompanied in (4) episodesof homelessness the past three (3) years' To be considered oR has had at least four homeless for a year o, -o.. must have been on the streetsor in an emergencyshelter (i.e. not ffansitional housing) during chronically homelessa person under the GeneralInstructions see these stayi. For furthei discussionof the dehnition of chronic homelessness, Other Key Definitions above. How many participants were chronically homeless individuals?

7.
a.

are Ethnicify. How manyparticipants in the following ethniccategories?

Hisnanic or Latino Non-Hispanic or Non-Latino

0
J

b.

Explanatory Notes: participants Each participant should be listed in only one category. The total number of participants in this table should equal the number of in question2b, columns t and2. 8. a.
D.

Race. How many participants are in the following racial categories?

Native AmericanIndian/Alaskan
Astan

d. f.
g

BlacVAfricanAmerican PacificIslander NativeHawaiian/Other White Native & White Americanlndian/Alaskan

Asian & White Blaclc/African American & White Native & BlacVAfrican American American Indian"/Alaskan

h.

OtherMulti-Racial
Explanatory Notes: be nach partlcipant should be listed in only one category. A participant whose race does not correspond to categoriesa through i should counted in j, Other Multi Racial. The total number of participants in this table shouid equal the number of participants in question 2b, columns I and 2. If using HMIS data, you may combine HMIS race responsecategoriesto generatethe APR responsecategories. 9a, Special Needs. How many participants have the following? Participants may have more than one. If so, count them in ali applicable categories. For each condition, also indicate the number that were chronically homeless. chronic All
a.

Mental illness

4 I

b.
c.

Alcoholabuse Drug abuse diseases HIV/AIDS andrelated disability Developmental

Phvsicaldisabilitv Domesticviolence

2 2

f.
b'

1
n

specifu) Other(please h. NONE 9b. Howmanyoftheparticipantsaredisabled? (0)

ExplanatoryNotes: in underOther Key Definitions theGenerai Condition" see of meet whichparticipants HUD's definition "disabled," "Disabling to determine Instructions. the in sleptin the followingplaces the weekprior to entering project? (For each 10 . 10. prior Living Situation. How manyparticipants in 2b, in one choose place. The total numberof participants the "Ail" coiumnshouldequalthe numberof participants question participant, one) sleptin the following places.(Choose participants how manychronically homeless columns1 and2). Also, indicate
HUD-40118

Ail b.
c. d.
e.

Chronic

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

persons for housing homeless Transitional

Psvchiatric facility* Substanceabuse freatment facilify* Hospitalx Jail/prison*

1,,:.

+':-: i
{j -.'r-.::: i

"

t
g

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

h.
l.

siruation Domestic ence viol Livins with relatives/friends

Rental housins Other (please specify)
J

l :. ,

;;1 -:,ii.i;11".. :
- , .ti: :,t I

k.

*Ifa participant facility,hospital, orjail), but wastherelessthan abuse freatment facility, substance camefiom an institution(psychiatric faciliry,he/she in the shouldbe counted eitherthe shelter beforeentering freatment 30 daysandwas iiving on the streetor in emergency as category, appropriate. street shelter or

Completequestions11 - 15 for all participants who left during the operating year (from 2c, columns I and2). The term participant means single persons and adults in families. It does not include children or caregivers. The term chronically homelessperson means an unaccompaniedhomelessindividual with a disabling condition who has either been continuously in homelessfor a year or more OR has had at least four (4) episodesof homelessness the past three (3) years.To be considered chronically homelessa person must have been on the streetsor in an emergency shelter (i.e. not transitional housing) during thesestays.

year,how many who left duringthe operating 11. Amount and Sourceof Monthly Incomeat Entry and at Exit. Of thoseparticip4nts placethemonthlyincomelevel andeach of participants wereat eachmonthlyincomeievel andwith eachsource income? Also, please of in persons the second columnof eachchart. Thenumber participants ChartA andB in source incomefor chronically homeless of shouldbe the same. AII
A. Monthly Income at Entry No income

Chmnic At C. IncomeSources Entrv SecurifyIncome(SSI) Supplemental

n

AII

Chronic

b.
d.

s1- 50
$ls

(SSDI) Income Disability SocialSecurify SocialSecuriry PubiicAssistance General (TANF) Aid Temporary to NeedyFamilies (SCHIP) Program StateChildren'sHealthInsurance
VeteransBenefits

s250
- $500

1
1

d.

$50 - $1, 00 0
f
g

s1001$1500
$1501$200 0 + $2001
h.
I

h.

Employrnent Income

Benefits Unemployrnent
Veterans Health Care Medicaid Food Stamps

J
t.

I
n.

specify) m.. Other(please

No FinancialResources

AII B. MonthlyIncome at Exit

Chrcnic D. Income Sourcesat Exit

Chonic

t0

HUD-40118

No income

b.
d

$ 1-150

b.
c. d.

(SSI) Income Security Supplemental (SSDD lncome Security Disabiiity Social SocialSecuriry PublicAssistance General
Temporary Aid to Needy Families (TANF)

s151 $250 r $25 - 550 0 $501 S 1 ,0 0 0

f.

2
f,
o

$1001- 5 0 0 $1

(SCHIP) Health Insurance Program State Children's Veterans Benefits Employrnent Income
Unemployment Benefits

h.

s2000 $150r+ $2001

h.
I

J
1,

Veterans HealthCare
Medicaid Food Stamps

I
m. n.

Other(please specify)
No FinancialResources

Explanatory Notes: Table A: Monthly income at entry refers to the participant's monthly income on the day he/sheenteredthe program (i.e., on the program entry date or as closeas possibleto that day). You should not report on incomereceivedbeforeenteringthe program or income received during the program stay. Table B: Monthly income at exit refersto the participant'smonthly income on the day he/sheleft the program (i.e., on the program exit date or as close as possible to that day). You should not report on income received during the progam stay. the Table C: Income sourcesat entry refersto the participant'ssourcesof income on the day he/sheentered program (i.e., on the program entry date or as close as possible to that day). You should not report on sourcesofincome received before entering the program or income received during the program stay. Participants with no income at the time of program entry should be reported in category n, No Financial Resources. Table D: Income sourcesat exit refers to the participant's sourcesof income on the day he/sheleft the program (i.e., on the program exit date or as close as possible to that day). You should not report on sourcesof income received during the pro$am stay. Participants with no income at the time of program exit should be reported in category n, No Financial Resources.

12a. Of those participants who left during the operating year (from 2c, columns I and 2), how many were in the projdct for the following lengths of time? Also, pleaseplace the length of stay for chronically homeless personswho E[t during the operating year in the second column.

AII
b. d. f.
o

Chronic

Lessthan 1 month I to 2 months

3 - 6 months 7 months - 12 months 13months - 24 months

25m on th s -3 v e a rs
4yea rs- 5y ear s 6 vears - '/ vears
I

h.

8 vears 10vears Over10vears Notes: Explanatory Iftheparticipanthasonlyone Computeeachparticipant'slengthofstayusingtheparticipant'sprogramentrydateandprogramexitdate. year,calculate the entrydatefrom the programexit date. If the program lengthof stayby subtracting program exit dateduringthe operating programstay(by subtracting year,calculate lengthofstay for each the participant multipleprogramexit dates duringthe operating has the programstay)andaddthemtogether produce cumulative to a progam entrydatefrom the program exit datefor each lengthof stay, Each in participant u'ith shouldbe associated only onelengthof staycategory.Thetotalnumberof participants the first column("A11") should in 2c, 1 the of equal number participants question columns and2.

1l

HlrD-40118

2)' 1 year who participants did not leayeduringtheoperating (from2d,columns artd how long l2b_ Lengthof Stayin program. For those persons who did not leaveduringthe chronically homeless placethe lengthof stayfor havJtheybeenin the ploject? Also, please column. yearin the second operating
All b. c. d. f. Less than I month 1 to 2 months Chronic

3 - 6 months
7 months - 12 months

13months 24 months 25m ont hs - 3 y e a rs

4 ye ars-5yea r s

5 6
A

s.
h.
1.

6y ear s - T y e a rs
8 vears- 10 years Over i0 years

t.

Notes: Explanatory Tocalculate Computeeachparticipant'slengthofstayusingtheparticipant'sprogramentrydateandthelastdayoftheoperatingyear. with year. Eachparticipant shouldbe associated only one programenfrydatefrom the last dayof the operating lengihof stay,iubtractthe 2d, in in lenglh of staycategory.The total numberof participants the first column("All") shouldequalthenumberof participants question 1, columns and2. year(from 2c, columnsI and2), how manyleft who left theprojectduringthe operating for 13. Reasons Leaving. Of thoseparticipants incluile onlythe primary reason. The totalnumberof participants for multiplereasons, left If for the foilowingreasons? a participant placethe primary 2c, in in the hrst column("All") shouldequalthe numberof participants question columns1 and2. Also, please column. yearin the second personswho left the projectduringthe operating for reason chronicallyhomeless
All Left for a housing opporhrnity before completing progam b. Chronic

program Compieted
Non-pa1'rnentof rent/occupancy charge Non-compliance with proj ect Criminal /destruction of properfy / violence ^ctivity Reached'maximumtime allowed in project
I

d,

f.
b.

Needs could not be met bY Project

h.

with Disagreement rules/persons

Death

J
1.

specify) Other(please
Unknown/disappeared

t2

HUD-40118

following 14. Destination. of thoseparticipantswho left during the operatingyear (from 2c, columns 1 and 2), how many left for the ofchronically homelesspersons who left during the operatingyear in the second destination?Also, pleaie place the destination

column All PERMANENT(a-h) b.

Rental house or apartment (no subsidy)

Chronic

PublicHousing 8 Section PlusCare Shelter

HOME subsidizedhouse or apartment

f.
g

Other subsidizedhouse or apartment

Homeovrmership Movedin with family or friends persons housing homeless for Transitional
Moved in with family or friends

h.

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

j
l-

K.

hospital Psychiatric
Inpatient alcohol or other drug freatment facility

I
m.

Jail/prison Emergency shelter Othersupportive housing

Placesnot meant for human habitation (e.g. street)

EMERGENCYSHELTER(n) OTHER(o-q)

n. o.

p. q.
LINKNOWN
I.

specify) Other(please Unknown

ExplanatoryNotes: provided.The response combine upon leavingthe program usingthe categories categories destination Identify eachparticipant's publichousing, etc.) (e.g.,rentalhouseor aparfment, homeownership, and "tenure"(e.g.,permanent, transitional, etc.). "destination" response, be sureto look at all ofthe response and categories the before Consider bothdestination tenureto determine mostappropriate and category. of makinga selection. tablebelowprovidesa brief description eachresponse The category eitherthe first columnof the tableor in both columns theparticipant in if undereachdestination is Enterthe numberof participants per The total numberof participants thefirst column in for chronically homeless. Only onereason leavingshouldbe recorded participant. 2c, ("All") shouldequalthenumberof participants question columnsI and2. in Tenure
Permanent
a,

Destination
Rental house or apartment(no subsidv)

Description Participant is moving to an apartmentor house without any subsidy. Participantis movins to a oublic housineunit. Participantwill use a housing choicevoucher(formerly known as a Section 8 voucher) to rent a house or aDartment.

b.

Publichousine Section 8 Shelter PlusCare or house HOME subsidized apanment houseor aparfment Othersubsidized

d.

h. Transitional
I

Homeownership Moved in with family or friends

Transitional housing for homeless people

Moved in with family or friends

Psvchiatrichospital

is by Participant moving to a unit funded the Shelter PlusCare prosram(e.e.,TBA, SRA,PRA, Section SRO). 8 provided the is Participant moving to a unit with rentalassistance by or assistance). HOME program(tenant-based proiect-based program is by otherthan Participant movingto a unit subsidized some public housing,housingchoicevoucher (formerlySection8), program PlusCare. HOME. or Shelter Participant movins to a unit thathe/she purchased. is has Participant moving in with family or friendsandexpects iive there is to for 90 daysor more. Participant moving into a unit funded a transitional is by housing prograrn homeless people (e.g., for transitional housing funded through Housins Proeram). theSuoportive Participant moving in with family or friendsandexpects live there is to lessthan90 davs.
Participant is moving to a psychiatric hospital.

Institution

t.

l3

HUD-40118

Inoatient alcohol or other drug

facilitY' hol or drugtreatment

Participantis moving to a aii or orison. people' Prrt .tpaxt ts ttot"tg to an emergency shelter for homeless

shelter EmergencY housing Othersupportive

housingthat doesnot correspond pa,tt"rpfi is rr"vtrg into supportive (a-h)andis not transitional housingcategories to anytfthe permanent (i), people suc@ for housine homeless
t" a place not meant for human habitation, such t*"*t"g P.tt-p*t as a car. park, sidewalk, or abandonedbuilding.

not Places meant lor human Other (pleasespecifY)

to pa.ti+ant is movingto a placethatdoesnot correspond anyof the

Thi. t.tpont. category should be used if you are unsure about where the participant is moving or if the participant has disappearedand there is no way to find out where he/sbe is.

Prograrus should report *HLID errcourages programs to lintit the use of the "Other Supportive Housing" APR responsecategory' (i) through (i), respectively are pernranent or transitional tn ipn categories (a) through (h) or in c(rtegories destittations to housing that shelters should be reported in category fu)' Exits ro enxergency year (from 2, columns 1 and 2), how many received the 15. Supportive Services. Of those participants who lgft during the operating project? Also, pleaseplace the supportive servicesreceived for chronically following supportrve servicesduring their time in the Participants may have received multiple servicesand a1l homeless partlcrpantsu,ho Ieft during the operating yearin the second column. services should be reported in the table' All Outreach Chronic

b.
u.

Casemanagement Life skiils (outside of casemanagement) Alcohol or drug abuseservtces Mental health services

2 2 2
1
I

services HIV/AID S-related

c'
h.

Other health care services

Education
Housing placement Emplol,rnent asslstance Child care Transportation z

J
t.

Legal

n.

specifY) Other(please

14

HUD-40118

Underobjectives,listyourmeasurableobjectivesforthisoperatingyear(fromyourapplication,Technica 16. OverallProsramGoals. yourprogress meeting objectives. in describe the goals listedbelow. UnderProgress, of or Submission, APR)for each thethree year. for objectives thenextoperating the specify measurable Year'sObjectives, UnderNext Operating z. ResidentialStability of Objectives: 70%o participants will remain in Shelter Plus Care housing for at least one year. PiusCare housing at least year. for in one have Progress: Exceeded or 20 of22 participants remained Shelter 91o/o Objectives: 50% of participants will remain in Shelter Plus care housing for at least fwo years Progress: Exceeded.86Voor 19 of 22 of participants have remainedin Shelter Plus Care housing for at leasttwo years; will Year'sObjectives:50o/o 11 of 22 of participants remainin ShelterPlus care housingfor at least two or Next Operating years

b.

Increased Skills or Income

partor full-time year. will employment duringthe operating objectives: % of participants enteror Gontinue 25% many of the residents not employable are Progress: Not Achieved: Unfortunately, becauseof deteriorating health abuseand or mentalhealthissues, We havefocusedon building or becauseof on goingsubstance theirlife skills and helpingthem receivequalified subsidizes such as GA. We havealso assisted them with temporary and workingas extrasin the Will SmithMovie. employment such as passingout leaflets Next Operating Year'sObjectives: year. the operating part or fulltime employment will 25o/o participants enteror continue of during

program training year. an andior vocational a Objectives: willeither 15% enter continue educational or during operating the enteredor continued education Progress:Substantially Achieved.13.6%or 3 of 22 participants an and /or vocational trainingprogramduringthe year. an program Year's 15% enter continue educational or and/or vocational a NextOperating Objectives: willeither training during year. theoperating

c.

GreaterSelf-determination

who need to reunify withtheirchildren, be reunited Objectives: Objectives: 50% pf households will withtheirchildren by placementin ShelterPlus Care housing housedat Glide Progress:No families Next Operating Year'sObjectives: 50% pf households who needto reunify with theirchildren, be reunited with will in theirchildrenby placement ShelterPlusCare housing. parentswill retaincustodyof, and carefor, theirchildren. 80% of participant Objectives: Progress: No familieshousedat Glide parents retaincustodyof, and carefor, theirchildren. Year'sObjectives: 80% of padicipant will Next Operating

l5

HUD4OI r8

17c. (SI/P-SSO projects do answer Ernswer l7b. SROrecipients answer17a. S+Crecipients 17. Beds. SIIP recipients

not completethis question)

a. SHP. How manybedswereincludedin the application approved riis projectunder'Cunent Level' andunder'New Effort'? for How manyof these New Effort bedswereactuallyin placeat the endof the operatingyeal.?

CurrentLevel New Effort New Eflort in Piace Numberof Beds: b. S+C. How manybedsanddwellingunitswerebeingassisted with projectfundsat the endof the operating year? (Includebedsfor all participants, otherfamily members, caregivers.) and Numberof Beds: 20 Numberof Dwelling Units: 20 c. SRO. How manydwellingunitswerebeingassisted the endof the operatingyeari? at (Includeunitsoccupied "in place"non-homeless persons by who qualiff for assistance.) Numberof Dwellins Units:

t6

HUD40Il8

Fart II: Financial trnformation

18. Supportive Services. was spentduring For SupportiveHousine (SHp), this exhibit provides information to HLID on how SHP funding for supporliveservices of SHP funding spent on thesesupportiveservices.Include HMIS costsunder "Other". the opeiating year, Enter the amount from all Specify the value ofsupportive services match requirement. For Shelterplus Care (S+C), this exhibit tracksthe supportiveservices should keep that can be countedas match that all homelesspersonsreceivedduring the operating year. (S+C grantees sources documentationon file, including source,amount,and type ofsupportive services.) personsduring the For Section 8 SRO, this exhibit providesinformation to HIID on the value of supportivesetvicesreceivedby homeless operating year.

Supportive Services
Oukeach b. Case management Life skills (outside of casemanagement) d. Alcohol and drus abuseservtces Mental health services f
I

Dollars

/ 449,432.00

/ 21.772.31 / 26,467.09

AIDS-relatedservices Other health care services Education Housing placement

h.

l.
t.

Emolovment assistance

Child care
Transportation

m. n.
U.

Legal Other (please specify)

TOTAL (Sumof a through)

497,671.40

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

497,671.40

1lt

HUD-40118

andAdminisfration Activities opgratile clt*lryTservices' supportive Frogram:.Leasing, Housing year'For expansion lg. Supportive eachoperating charts thJse mustcomplete Houiing Program

recei'ing fundingunderthe Suppoffrve Ail grantees to be IfSHpgrantfundsareforrheexpansi.""r"pr.-.*istiighomelesrruJiiitir,onlythepeople-andexpendituresfortheadditional projects: used uo.u*rntation of resources is not required * unvgint amendm.nir. as may made expansion be included, in theoriginaluppriruioi any notincrude expenditures by HUD andAuditors.Do be but with thisreport should kepton f,i.;;; ;;;r,bi"lnspection submiued
beforethe SHP was executed.

yearfor eachactivity match expendedduringthe operating Enter the amount of SHP grant funds and cash Summaryof ExPenditures. as be total should thesame the SHPsupportlve services The SHP supportive add Thistableshould uPbothtlorirootutty and vertically
servicesin Total Expenditures

SupportiveServices

Costs Operating
HMIS Activities Administration

ff iint eres to n a n y l o a n o r m o r tg a g e m a yn o tb e sh o wn a sa n o p e Ia tlngexpense

sources of cash Match. sheets,as necessary.

column, above,in the following categories'use additional Enter the sourcesof cashidentified in the cash Match

Amounl
a.

Grantee/project sPonsor casn Lo*l gou"*-ent (PleasesPecifY)

D.

c.

specify) Stut"gou.rnment(please

d.

(please specify) govemment nederal C.".."ttry D.*l"ptent block Grant(CDBG)

sPecifY) Foundations(Please

f.

ptiuut" "*tt

resources(please specify)

/ charge fees Occupancy Total

18 HUD-40i

18

20. Supportive Housing Frogram: Acquisition, R.ehabiiitation, and New Construction thesecharts the yearoneAPR in mustcomplete or rehabilitation, new construction SHPfundsfor acquisition, that All grantees received enough cashto at leastequallymatchthe amountof SHPfunds has demonstrate HUD thatthegrantee contributed to onlyl This exhibitwill wereprovided notrequired be submitted is to that Documentation matchingfunds or for rehabilitation, newconstruction. spent acquisition, inspection HIID andAuditors. by with thisreport should kepton file for possible but be yearfor eachactivity. duringthe operating of Summaryof Expenditures. Enterthe amount SHPgrantfundsandcashmatchexpended
SHP Funds Acquisition
h

Cash Match

TotalExpendirures

Rehabilitation
New construction

d.

Total

CashMatch. Enterthe sources cashidentifiedin the CashMatchcolumn,above, the followingcategories.Use of in additional sheets. necessary. as Amount
Granteeiprojectsponsor cash

b.

Local government (please specify)

government (please State specifr)

i i.t

d.

govemment (piease Federal specify) Block Grant(CDBG) Communitv Development

(please Foundations specify)

f.

Private cash resources(please specify)

Occupancy charge/ fees Total

h.

r9

HUD-401i8

O,ryI,Y FOR HMIS ACTTWTTES

21. For Supportive llousine (SHP) - HMIS Activities was spentduring the operating year. Enter This exhibit provides information to HtlD on how SHP-HMIS funding for supportiveservices the amountof SHP-HMIS funding spenton theseactivities.

HMIS Activities Only Central Server(s) PersonalComputers and Printers

...:' -,,
Software / User Licens Software Installation

:4 i-tl!i::

:i*i;i

,...'l

Subtotal fl2ining by Third Parties Hostins / Technical Services Programming: System Interface Programming: Data Conversion

Assessment Setup and Security

Online Connectivitv (Internet Access Facilitation Subtotal Project Management / Coordination

Technical Assistance and Tra

ort Administrative Supp Staff

Costs Operational

20

HUD-401 l8

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

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

2l

HUD-40118

Report PersonsServed Worksheet - HUD Annual Progress

The Coilection of the protected personal Information (PPI) on this form is done with the knowledge or consentof the clients. PPI is only used for the following purpose: Accurate completion of the Annual ProgressReport (APR) for the Contiluum of Care (CoC) Homeless AssistanceProgram in which the client is enrolled. and the Report. Instructions needed complete AnnuaiProgress to to is This worksheet optionalandis intended help you coliectinformation not sutrmitthis worksheetto HUD. Codesfollow. Do
Number of Months in Project (calculate) 12a Number of Months in Project -Participant did not leave (calculate) 12b

(SI Non-Homeless Only) ( Yi N ) 4

Persons Served Worksheet (continued)

Collection of the ProtectedPersonalInformation (PPI) on this form is done with the knowledge ot coruent of the clients. The PPI is only used for the following purpose: Accurate completion of the Annual ProgressReporl (APR) for the Continuum of Care (CoC) Homeless AssistanceProgram in which the client is effolled.

Do not submit this worksheet to HUD Ethnicity Veterans Chronically No (code) Homeless Status(Y,AI) (Y.D{) 7 6a
6b

Race (code) 8

SpecialNeeds (code) 9a

SpecialNeeds (code) 9b

Prior
L' vr r r E

Situation (code )

Monthly Income At Project Entry 1l a

Monthly lncome At Project Exit 1 1b

!
A

((
1

10

22

HUD-40118

z)

HUD-401i8

Fersons Served Worksheet (continued) Collection theProtected of Personal Information (PPI) on this form is donewith theknowledge consent the clients. The or of PPIis onlyused thefollowingpurpose: for Accurate completion the AnnualProgress of Report(APR) for the Continuum Care(CoC)Homeless programin of Assistance whichthe clientis enrolled.
Do not submitthis worksheet HUD to
Reasonfor leaving Program (code) 13

Instructions and Codes for PersonsServed Worksheet The use of th is wo rkshe et is opt ional. I t was des igne d t o help y ou colle ct info r m at ion on par t ic ipant s neede d t o complete the An nu al Pr ogr es s Repor t . I f t he w orkshee t is u pd ate d a s par t ic ipant s m ov e in and m ov e out of you r p roje ct, mo s t of t he inf or m at ion r equir ed f o r comple tion will be c ont ained in t he wor k s heet . D o n o t subm it this worksh eet wit h t he APR. F or projects tha t serve fam ilies , HUD only r equir es reporting o n th e n umb er of c hildr en s er v ed, and t he a ge and ge nd er o f the se c hildr en. O nly nam e, r elationship , d ate of birth, and age on t he wor k s heet
'l^

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 ad u l ts a number, but not each family member. Use this number to transfer to the other pages of the worksheet. B e g i n n i n g w i t h n u m b e r 4 , t h e n u m b e r s i n t h e c ol u m n s refer to the questions on the APR form. If any q u e s t i o n s a r e a n s w e r e d w i t h " O t h e r , " p l e a s e e n te r th e s p e c i f i c " O t h e r " a n s w e r f o r i n c l u s i o n l n t h e A p R. Participant Number. This column allows you to either number participants consecutively or to assign a case number, One number should be assigned to each adult.

HUD-40118

will not be r epor t ed t o Nam e . Na mes o f per s ons HU D. Th e u se o f nam es is f or y our r ec or d k eepi n g conve nie nce. R elatio nship . En t er t he appr opr iat e r elat ions hi p . E xample s in clu de : Self , Head of hous ehold, Spo u s e , child. E ntry Date . En ter dat e par t ic ipant ent er ed t he project. Usua lly t his will be t he dat e of ac t ual physica l mo ve -in f or a hous ing pr ojec t . E xit Da te. En ter dat e par t ic ipant lef t t he pr oiec t . U sually th is will be t he dat e t he par t ic ipant physically moved out f or a hous ing pr ojec t . Do n o t includ e a pa rticip ant who t em por ar ily lef t t he p r o j e c t and is e xp ected to r et ur n in les s t han 90 day s ( e . g . , hosp italizatio n). 4. Income -elig ibl e Non- hom eles s in SRO . Th e S R O pro gra m allo ws as s is t anc e t o unit s oc c upied b y Se ctio n 8 incom e- eligible per s ons r es iding a t t h e SRO p rior to r ehabilit at ion. For SRO pr ojec t s on ly, ind ica te whet her t he par t ic ipant is an income -elig ibl e, non- hom eles s per s on ( Y) o r n o t (N). SHP a nd S+ C pr ojec t s s hould s k ip t his i t e m .

a. Mental illness b. Alcohol abuse c. Drug abuse d. HIV/AIDS and related diseases e. Developmental disability f. Physical disabilities g. Domestic violence h. Other (please specify) 9 b . E n t e r t h e n u m b e r o f p a r t i c i p a n t s w i t h a d i sa b i l i ty 1 0 . P r i o r L i v i n g S i t u a t i o n . E n t e r t h e l e t t e r th a t b e st d e s c r i b e s w h e r e t h e p a r t i c i p a n t s l e p t i n th e w e e k prior to entering the project. Do not double count. 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 on , e tc.) b. Emergency shelter c. Transitional housing for homeless persons d. Psychiatric facility* e. Substance abuse treatment facility* f. Hospital* g. Jail/prisont 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 l e s s t h a n 3 0 d a y s a n d w a s l i v i n g o n th e s t r e e t o r i n a n e m e r g e n c y s h e l t e r b e f o r e e nte r i n g th e f a c i l i t y , h e / s h e s h o u l d b e c o u n t e d i n e i t h e r th e str e e t or shelter category, as appropriate. Instruction Codes for Persons Served Wo r k s h e e t ( c o n t i n u e d ) 1 l a . G r o s s M o n t h l y I n c o m e a t P r o j e c t E n tr y. E n t e r t h e a m o u n t o f g r o s s m o n t h l y i n c om e th e p a r t i c i p a n t i s r e c e i v i n g a t e n t r y i n t o t h e p r o j e ct. 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. En te r the gross monthiy income the participant is receiving when exiting the project. l l c . I n c o m e S o u r c e s R e c e i v e d a t P r o j e c t E n tr y. 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 pa n t i s receiving at entry to the project. a. Supplemental Security Income (SSI) b . S o c i a l S e c u r i t y D i s a b i l i t y I n s u r a n c e ( SSD I) c. Social Security d. General Public Assistance e . T e m p o r a r y A i d N e e d y F a m i l i e s ( T A NF) f. State Children's Health Insurance Program (SCHIP) g. Veterans benefits h. Empioyment income i. Unemployment benefits j. Veterans Health Care k. Medicaid L Food Stamps m. Other (please specify) n. No Financial Resources

5a. Da te o f Birth . Ent er dat e of bir t h inc ludins mo nth , da y, a nd y ear . 5b. Age . En ter age at ent r y . 5c. Gen de r. Ente r appr opr iat e let t er f or gende r . M-Ma le F- Fem ale. 6a. Vete ran s Sta t us . I ndic at e if t he par t ic ipan t i s a vete ran . Ple as e not e: A v et er an is any one w h o ha s ever be en on ac t iv e m ilit ar y dut y s t at us f o r the Unite d Stat es . 6b. Ch ron ica lly hom eles s per s on. I ndic at e t he n umb er of pa r t ic ipant s t hat ar e c hr onic ally h ome less. l. Ethn icity. Ent er appr opr iat e let t er f or et hn i c gro up . a. Hispa nic o r Lat ino b. No n-Hispa nic or Non- Lat ino

Rac e. E nt er a p p ro p ri a tel e tte r fo r ra c e . a. A m er ic an I n d i a n o r Al a s k a nN a ti v e b. A s ian c . B lac k or A fri c a n -A m e ri c a n d. Nat iv e Haw a i i a n o r O th e r P a c i fi c Is l a n der e. W hit e N f . A m er ic an I n d i a n /A l a s k a n a ti v e & Wh i te g. A s ian & W h i te h. B lac k / A f r ic a n A m e ri c a n & Wh i te N i. A m er ic an I n d i a n /Al a s k a n a ti v e & B lac k / A f r ica n A m e ri c a n j. O t her M ult i -R a c i a l 9 a . S pec ial Need s . En te r th e l e tte r(s )fo r th e th c at egor y ( ies) a t d e s c ri b eth e p a rti c i p a n t' s dis abiiit y ( ies ).(Yo u m a y d o u b l e c o u n t).

25

HUD-40118

lld.Incorne So urces Rec eiv ed at Pr ojec t Ex it . F .nre r a ll tvne s n finc om e t he par t ic ipant is , e^.;,,i-- ,P 'vrv! nrn ial{ ex it . ( Us e c odes as in 11c .) a+ , . v !,Y ," 6 q ""' v' r 12a Leng th in Sta y in Pr ogr am . Calc ulat ed it em . (S ee Entry Date and Ex it Dat e abov e. ) l2b. Le ng th o f Sta y in Pr ogr am . ( Par t ic ipant did not le ave du ring t he oper at ing y ear . How long have the y be en in t he pr ojec t ?) 13. R eason for L ea vi ng Pr ojec t . Ent er t he pr im ar y reason why the p ar t ic ipant lef t t he pr ojec t . (C omple te o nly for par t ic ipant s who lef t t he proje ct a nd are n ot ex pec t ed t o r et ur n wit hin 9 0 days. a. Left for a housing opportunity before com p letin g the pr ogr am b. Co mple ted pro gr am c. Non -pa yme nt o f r ent / oc c upanc y c har ge d. Non -co mplia nce wit h pr ojec t e. Crimin al activi t y / des t r uc t ion of pr oper t y / violen ce f. Re ache d maxim um t im e allowed in pr ojec t g. Ne ed s cou ld no t be m et by pr ojec t h. Disa gre eme nt wit h r ules / per s ons i. De ath j. Oth er (ple ase s pec if y ) k. Un kn own /disap pear ed

l5.Supportive Services. Enter all types of s u p p o r t i v e s e r v i c e s t h e p a r t i c i p a n t r e c e i v ed d u r i n g the time in the project.

a.outr eac h

b. Case management c . L i f e s k i l l s ( o u t s i d e o f c a s e m a n a g e m e n t) d. Alcohol or drug abuse services e. Mental health services f. HIV/AIDS-related services g. Other health care services h. Education i. Housing placement j. Employment assistance k. Child care l. Transportation m. Legai n. Other (please specify)

[4. D estina tion . Enter t he des t inat ion of t hos e leaving th e p roje c t . P erma ne nt: a . Ren tal ho us e or apar t m ent ( no s ubs idy ) b. Pub lic Ho us ing c. Section 8 d. Sh elte r Plu s Car e e. HOME sub s idiz ed hous e or apar t m ent f. Othe r su bs idiz ed hous e or apar t m ent g. Ho meo wne r s hip h . Mo ve d in wit h f am iiy or f r iends T ran sitio n al: i. Tran sitio na l hous ing f or hom eles s per s on s j. Mo ve d in wit h f am ily or f r iends I n stitu ti o n : k. Psychia tric hos pit al. l, In pa tien t a lc ohol or dr ug t r eat m ent f ac ility
m Iqil/nricnn

E m erg en cy: , ^- E* ^ -^ Eer r wJ ^ " s helt er Oth er: o . Othe r sup por liv e hous ing. p. Places n ot m eant f or hum an habit at ion (e .g., stre et) q. Oth er (p lea s e s pec if y ) U nkn own : r. Unkno wn

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HUD-40118