OMB A pprova)N o.

2506-014 5(ex p- 11i 30/2009)

U. S. Department of Housing and Urban Development Office of Conrmunity Pianning and Developntent

F'ATDV u \t/'V U

Report (APR) Annual Progress

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

HUD-40118

including the time forreviewing instructions' 33 to public reporting burden tor this collectlonofinformaLion is estimated average hoursper response, may rhe dataneeded,and iompleting and reviewingthe collection ofinfomlation. This agency gatheringand maintaining exisrlngdata sources, searchirrg trut.t ber. a to not cor.rduct sponsor, of anrl a peisonis not reqr-rired respondto, a collectionof infomation unlessthat collectiond'ispiays valid OMB contt'ol

General Instructions Purpose. The Annual Progress Report (APR) is a reportingtool that lfUD usesto track programprogressand assistance funding. processfor homeless accomplishments inform the Department's competitive and grants must submit 2 APR'S to HUD within 90 days aller Filing Requirements.Recipients HUD's homeless assistance of year. One copy of the reportmust be submitted the CommunityPlaming and Development to the end of each operatins (CPD) Division Director in the local HUD Field Office responsible managing grant. The other copy mustbe submitted for the to HtlD Headquarters, Attn: APR Data Editor, Room 7262, 451'/"'Street, of Department Housing and Urban Development, SW, Washington,DC. 20410. Failureto submit an APR will delayreceivinggrant funds and may result in a deternrination of lack of capacity for future funding. An APR nrust be submitted for eachoperatingyear in which HUD funding is plovided. or are Grantees that receivedSHP funding for new construction, acquisition, rehabilitation requiredto operate their facilities for year and every year throughoutthe 20 years. 20 years. They must submit an APR 90 daysafter the end of tire fust operating A separate reportmust be submifted eachHUD grantreceived. For ShelterPlus Care(S+C), a separate for APR mustbe submittedfor eachS*C conrponent. (seeExtension .F'or thosegrantees reporl coveringthat period mustbe subnritted receivingan extension, separate a below). Recordkeeping. Grantees must collect and rnaintaininformationon eachparticipantin order to completean APR. Optional worksheetsare attached. The worksheetsmay be used to record information manually or to design a computelized systemto store and tabulatethe infonlation. The worksheetsshould not be submified to HUD rvith the APR. Organization of the Report. The APR is organizedin the following maffrer: the in persons self-sufficiency, Part I: Project Progress.This portion of the report describes progress moving homeless to for documentingservices received,listrngproject goals,and accounting beds/units. by receivingfuirdingunderSHP, S+C, Part II: Financial Information. This portion of the reporl is completed all grantees and SRO. numbereverypage sequentially.Mark any questions !'inal Assembly of Report. ltter the entire report is assembled, that do your program with "N/A" for not applicable. (SeeSpecialInstructions SSOProjectsbelow.) for not apply to type is definedbe1ow.Note that a client's client,&iousehold Definitions of Client/Household Types. Each client/household type should be based on the client's age and/or householdcomposition at theprogram entry date closest to tlte start of tlte year. operatt.txg at Families - A family is a householdcomposedof two or more relatedpersons, leastone of who is a child accompanied by an adult or ajuvenile parent. by Singles not in Families - Persons accompanied children,tncludingpregnantwomen not accompanied other not by youth, are singlesnot in families. When two adultsor two unaccompanied youth plesent children and unaccompanied togetherfor selices, eachpersonshouldbe countedin singlesnot in famrlies.. Clients' householdstatusshouldbe year. Thrs deterrniledbasedon their householdcompositionat the programenhy dateclosestto the startof the operating meansthat pregnantwomen expected give birth during their programstay shouldstill be countedas singlesnot in to lar nilies . purposes APR repofiing, of Adults in Families - Within a family, an adult is any person 18 yearsof age or older. For tl.re composition the detennilation of whethera personis an adult in family shouldbe madebasedon their age and household g at tlre program entry dateclosestto the starl of the operatin yeat. by Children in Families - Children in Famrliesare defmedas childrenunderthe age of 18 accompanied one or mole adults (parent,relative or guardian). Children in families also includeboth a juvenile parentand the parent'schiid(ren). of For the putposesof APR reporting,the determination whethera personis a child in family shouldbe madebasedon to their age and householdcompositionat the programenhy dateclosest the startof the operatingyear. For exarnple,
HUD-40118

drtring of the opetattngyear oI at program enhy (if they entered clients who are iess than 1B years of age on the first day operatlng year' courseof the the operatng year; shouldbL countedas children even if they turn 18 during the persons in Families - Persons famrliesincludesadultsrn fanllies and childrenin famrlies. in

telTns applieddifferently are Other Key Definitions. The following termsare used in the APR. As indicated,in somecases, the funding is fiom SHP, S+C, or SRO. depending whether on homeless individr"ral personas "an unaccompanied Chronically homelessperson - HUD definesa chronicallyhomeless . .licahli-- U L for who haseitherbeen continuousiyhomeless a year or more OR has had at leastfour (4) wlt ll 4 ur J 4ulllls ",itl" ^lndition a chronicallyhomeless, personmust havebeen on of in episodes homelessness the pastthree(3) years." To be considered shelter(i.e.,not in fransitionalhousing)during thesestays. the streets il an emergency or personis basedon the following components: HUD's defrnition of a chlonicallyhomeless . homeless individual has the samecharacteristics individual: an unaccompanied Unaccompanied homeless of a Singlenot in a Family (describedabove). . Disabling condition: seethe inshuctionsunder disablingcondition(below) to determinewhethel a client is disabled. Did not leave the program - This terrnrefers to clients who were in the programon the last day of the operatingyear-. Disabling condition - HUD definesa disablingcondition as: (1) A disability as defrnedin Section223 of the Social Security Act; (2) a physical, menta| or emotional impair:mentwhich is (a) expectedto be of long-continued and indefinite duration, (b) substantially impedesan individual's abiiity to live independently,and (c) of such a nature that such ability enrrlrlhe irrrnrnriert more suitablehousingconditions;(3) a developmental disability as definedin section 102 of the by syndrome of or and Developmental DisabilitiesAssistance Bill of Rights Act; (4) the disease acquiredimmunodeficiency syndrome;or (5) a diagnosable any conditionsarising from the etiologicalagencyfor acquiredimmunodeficiency substance abusedisorder. progranr, Entered the program * Enteredthe program refers to the fust day a client receivesservices.For a residential the in the program'shousilg. For setvices,this datemay represent day the this datewould represent flustday of residence was provided, or the first date of a period of continuous participation in a service of program enrollment, the day a service t a ^ .1.i1_, ..,^-Lry,or monthly).
YY ! vr v J ,

For S+C and SRO programs, the program entry date is the date that the participant starts to receive rental assistance.For for and S+C, servicesprovided prior to this point are recognizedas necessary ouh'each,/enrollment are eligible to countas niatch. and that requested receivedan extensionof their grantterm fi'orn An Extension APR appliesto SHP and S+C grantees 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 citcle "yes" to indicate the APR is for an extension nerinri und nirele tls operatingyear for which the repofi is an extension. year3, For example,ifthe granteeis extending the granteeshould submit an APR as usual for year 3 and submit anotherAPR for thb extensionperiod, indicating the page. secondis an extensionand also circling year 3 on the signature Grantee rieans a direct recipientof the HUD award. s. Left the program - Left the programrefers to the last day a client receivesservice For a residentialprogram,this date the the in would representthe last day of residence the program's housing. For services, exit date may represent lastday serice. If a client leavesthe programtemporalily(e.g., a servicewas provided or the last dateof a per-iodof continuous for a hosnifaliz,ation) is expected return within 30 days,do not count that client as having left the program. to but and For S+C Drosrarrs,the programexit daterefers to the datethe parlicipantstopsreceivingrental assistauce is not T- - D_- ^^^. ewncnrerl r.crrrm S+C assisted rn housingwithin 90 days,the pelson participantrefums to S+C assisted housing. If the to ruu u^yLL

refums S+Cassisted to housing after90 days, that fromtheprogram.If theperson as should be considered exiting not this to is persolt considerednewparticipant. worksheet designed capture information. The is a
3 HUD_401 I8

in receivedby participants the S+C project which, in the aggregate, Match for S+C is the vaiue of supporliveservices provided over the life of the project. For SHP,matchis cash must at leastequalthe value of the S+C rental assistance "^^r +^ --^-:rtr the grantee's portion ofacquisition,rehabilitation, u Jsu L U P ru vl u new conshuction, operations and supportiveservices expenses. Operating year - For SHP progranx, the first operatingyearbeginsafter development activitiesfor acquisition, rehabilitation, and new conshuctionare complete, after a copy of the Certificateof Occupancy sentto the local HUD is office, andwhen the first participantis accepted into the project. For projectswithout acquisition, rehabilitation, new or conshuction, operatingstartdatebeginswhen the granteeaccepts first participant. For dedicated the the HMIS pro3ecrs, the operatingyearbeginswhen any eligible cost includedin the approvedproject budgetis incurred. For S+Q (gfu4, PRA and TRA components), first operatingyearbeginson the dateHUD signsthe grant agreement. the For S+C/SRO and for Sec.8 SRO, the first operatingyearbeginswith the effectivedateof the HousingAssistance Payments (HAp) Contract. To detennine which operathg year to circle on the APR cover page, begin counting from the initial grant operating start date and include renewal grants. For example,a project receiving an uritial grant for tll'ee yearsanda renewal grant for fwo yearswould circle years 1, 2, and3 respectively the APR cover sheetfor the initial grant and would circie 4 and 5 on respectively for the renewal grant. For any future renewal grants,the granteewould begin by circling 6 on the ApR cover sheet. Participants - The term participantrefersto Singlesnot in Famrliesand Adults in Familiesas definedabove. particioant doesnot includechildren or caregivers who live with the adultsassisted. Project Sponsor meansthe organization responsible carying out the daily operationof the project,if the for organization is an entity other than the grantee.

Special Instructions for Sunportive Service Only (SSO) Programs. SSOgrantees shouldcomplete questions, all unlessa wlitten agreement beenreachedwith the fie1doffice concemingwhich questions be answered has can using estimates, or in rare instances, skipped. Beiow is an exampleof how informationcould be derivedin a large,single-service SSOproject: A grantee/sponsor staff membercould be assigned collect informationfrom the organizations to housingthe participants.The staff person would contact theseindividual organizationsto requestinformation regarding the personsin thaitacllity that use the seryice.For participantsliving on the sheet,the grantee/project sponsormay provide estimates. Infonlation could be collected for eachparlicipant or for parlicipants receiving selices at a point-in-tiryre. If estimatesor point-in-time counts are used, the method used must be describedin the APR and the documentationkept on file, As with all projectsfundedunder HUD's homeiessness assistance grants,grantees operatingSSOprojectsare expected to conrpleteall APR questionsthat arc applicableto them. Note that all projectshave beenawaldedfundsas a result of responding the program goals of assisting to personsobtair/remainin penlanent housingand increase homeless their skills and income. The APR documents their progress meetingthesegoals. in In somecircumstances field offices and grantees may sign a wriften agreement concemingquestions that canbe answered usins estimates, in rare instances, or skipped. Seethe specialinsfmctions below for reportingon speciallypesof projects,suchas outleachonlyprojects, projectsproviding services childrenoniy, and h'ansporlation, to medical,de1ta1, othersingle,sirortand durationserviceprojects. SSOprogranu are a thild priorify for local HMIS implementation, followilg emergency shelters, transitional housingprogran.rs, programs,and permanentsupportivehousingprograrns.Once SSOprogramsare includedin the HMIS, SSb gr:antees outt'each will be able to answerall APR questions using their HMIS data. SSO grantees that arenot yet parlicipatingin HMIS wi-l1 need to collect datato answerthe APR questions usirigthe specialinshuctionsprovided above . Outreach Only Projects. Projectswhich are solely devotedto streetouheachand connection housilg and services to ar.e not requiredto frack participantsbeyondtheir contactwith personson the street. It is sufficientfor thesepioiectsto enter
HUD-101 18

Estimatesfor questions 5-9 are allowed' given that on inforrnarion questions1-10 (skippingquestions11-13and 17). questions' personal to may participar)ts be reluctanr answer numberof people,providing basic is that will demonstrare the grantee servingthe appropriate Alswering the questions of dernographiciniormation for Congress,demonstratingthat homelesspersons are being seled, demonstratingthe rypes they are receiving. are housingparticipants comected to, and the type of services are Hotline Projects. Hotline services similar to outreach only projects, but contactbefweengranteeand participantis often of very short duration - people enter and leave the program nearly simultaneously. It is sufficient for theseprojects to answer questions1-5 (skipping4), 10, and i4-19 (skippinglT). for Projects Providing Services To Children Only. Projectsthat provide child care,after schoolcare,counseling While the main focus of tireproject moving a family out of homelessness. children,etc. make an importantcontributiontoward 6-16 of the APR. Like all otherprojects, is providing services the children,it is the adultswho arereportedon in questions to gefting the families into housing and increasingthe families' incomes. Granteesmay skip this rype is also targeted toward (except17). question9; al1other questions shouldbe answered providea Transportation, Medical, Dental, and Other Single, Short-Duration Service Projects. Somegrantees duration focused ONLY indirectly on assistinghomelesspersonsto obtain/remainin pennanent single service of fairly short hor,rsing and increasetheir skrlls and incomes. It is sufficient for theseprojects to enter information on questions 1-10 and 14would have to it services, is unreasonable think that someone 19 (question17 may be skipped). However,with transpofiation to get a ride a fewblocks. to give their age,race, and ethnicifyto a bus driver provide a narrative,which gives the numberof rides given during the operatingyear, and providesestimates For theseservices, basedon the populationthat utilizes the service. on the abovestatistics serveddurilg the For Safe Haven (SH) Proiects. Granteesshouldreport on all participants Special Instructions operating year. Note: this is a changefrom prior instructions where granteeswere instructedto report on the first 25 participants served.

grantees ManagementInformation System(HMIS) Proiects.HMIS SpecialInstructions for Homeless

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

HUD-40118

THIS PAGE - TO BE COMPLETEDBY ALL GRANTEES

(JIAIIICC:

HUD Grant Project or Number:

of Cityand County San Francisco Deoartment HumanServices of

ProjectSponsor:

c501 048 cAo1

ProjectName:

Housing Mission Development Corporation

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

ParkHotels South
Reporting Period: (month/day/year)

xlt Cz tr: E+ Es no [u Us trs lro D r r D r z [ r : [ t+ [rs l ro []n l i s E rq Dzo

Indicateif extension: I Yes X[ No Indicateif renewal: X[ ves n No PreviousGrantNumbersfor this proiect:

from: 9/112006

ro: Bl31l07

cA01 c301 041 cA01 c401 046

Check the component the programon which you are reporting. for

Supportive Housing Program (SIf) Housrng LJ lranstllonal PermanentHousing for Homeless I with Disabilities Persons fl fl f, f] Safe Haven IrurovativeSupportive Housing SupportiveServicesOnly HMIS

Shelter Plus Care (S+C.r fl TenanrbasedRental Assistance(TRA) (SRA) X[ Sponsor-based RentalAssistance Projecrbased Rental Assistance(PRA) I (SRO) n SingleRoom Occupancy

Section8 ModerateRehabilitation n Single RoomOccupancy (Sec.8 SRO)

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

year,thisproject provided to 'lB unitsof permanent During thisoperating up housing homeless to individuals. of All the participants werefrom the streetsor emergency shelters and are livingwith at leastone specialneedrelated to mentalhealth, substance ab(use), HIV/AIDS. or
Name & Title of the Personwho can answer questions about this report Phone: (include area code)

CherylCanevari ProgramManager Resident of Services Mission Housing Development Corporation

Address:

(415)864-6432ex|.344
Fax Number: (include areacode)

4T4Valencia Suite280 St. San Francisco 94103 CA Address E-mail Cheryl m issionhousing.org @

(415)864-0378

I hereby certify that all the information stated herein is true and accurate.
Warning: HL,IDwillprosecutefalseclaimsandstatements. Convictionmayresultincriminal and/orcivilpenalties. (18U.S.C. 1001, 101 0,1 01 2131 U.S. C.3129. 3802)

H U D4 0 1 1 8

Name & Title of Authorized Grantee Official:

Signature & Date;

SteohanAdviento Program& GrantsAnalyst Programs Housing Homelessness & Agency HumanServices

Name and Title of Authorized Proiect Sponsor Official:

4
Signature & Date

irfuft*

Larry Carlo Del PresidenVCEO Mission Housing Development Corporation

HUD-40118

PART I. TO BE COMPLETED BY ALL GRANTEES(EXCEPT

HMTS)

ON INSTRUCTIONS PAGE3 OF THEAPR SPECIAL PLEASESEE GRA|ITEE& SSO Part I: ProjectProgress

1. Projected Level of Personsto be served at a given point in time. (This inlormation comesfiomtire mostrecentCoC ication apolicable this to
Number of SinglesNot in Families lo Number of Adults in Fan-riiies Number of Children in Families Nunber of Families

a.

ProiectedLevel Persons be servedat a given point in time to

2.

PersonsServedduring the operatingyear.

Number of SinglesNot in Families Number of Adults in Families Numbel of Children in Fami l i es
Nun.ibel of Far.ni'lies

Number on the first day ofthe operatingyear Number enteringprogramduring the operatingyear Number who left the program during the operating year Number in the program on the last day of the operating year (a +b -c)=d

17 2 2
II

b.
c.

d.

Explanatory notes: Types in the GeneralInstructionsaboveto detemine whtch clientsshouldbe countedas Singles SeeDefinitions of Client/Household Not in Families,Adults in Families,and Children in Families. Note that this table doesnot accountfor changes client,4rousehold that may in type a occur during the courseof the operatingyear. Instead,eachclient should be assigned single client,ftousehold type basedon the client's ageandior lrousehold compositionat theprogram entry date closestto the start of the operatingyear. In this way, eachclient is counted
i. ^ nl\/ ^n. a t he t ahla

Use the following graphic and explanations determjnewho shouldbe countedin rows a-d: to

i #

in on Clieni program lirsldayof year,leftduring operating lhe

year: count in2a and2c

in on Client program f;rstday y ear ofoper atr ng andl as l y : dayofoper ati ngear c ount i n 2a and2d.
l+ ..."...".'..< Cl ent enlered and leff program before starl oi operatrrg year: do nol count In queslion2. Clienl enlered progfam during operatingyear and slill in program on last day !f year: count in 2b and 2d. Client entered and leff program during operating year: count in 2b and 2c.

Fict day ofthe operating year

Last day ofthe operaling year

^.
b.

year:Thisrow includes clients all whoentered program the Numberon thefirst day ofthe operating before firstdayofthe the
n,rprorinc 'aar on; iid not leavethe program until after the first day ofthe operatingyear. Nurnber enteringthe program during the operatingyear: This row includes clientswho entered programon or aftertheflrst all the J..,^ fti"^ n nn rotinc y ear , upt oandinc ludingt hela s t d a y o f t h e o p e r a t i n g y e a r . o r c l i e n t s w i t h m u l t i p l e p r o g r a n l e n t r y d a te s,u se th e F a,irr\/,4.ra t^ year.Do not countthe clientmorethan onceevenif he/she entered progr.am the mor.e than ^l^cacr rhe startof the operating on cedu ringth e o per at ing , ear . )

c.

Number who left during the operating year: This row includesall clientswho left the programon or after the first day of the n^erctint '^ and including the last day of the operatingyear. For clientswith multiple progam exit dates,usethe exit date
H U D -401 18

year closestto the end ofthe operattng the operattngyear.

d,

Thi srow i ncl udesal l cl i entsw how erei ntheprogr am asof t hef ir st Num ber inilr ep ro g ra mo n th e l a s td a y o fth e o perati ngyear: of year.Thenumber duringtheoperating year ,4c., rhennererino or who entered nf rear duringthe operating and whodid not leave
uqj ur r Lr r

Fo r clien tso rfamilie s int hepr ogr am ont helas t day of t h e o p e r a t i n g y e a r i s c a l c u l a t e d b a s e d o n t h e r e s p o n s e s t o r o w s 2 a th r o u g h 2 c cach column, add the numberof clientsor families in row 2a to the numberof clientsor familiesin row 2b and subtractthe number of 2d: 2a + 2b - 2c. clients or families in row 2c. Therefore,

3.

Project Capacity.
Numbel of SinglesNot in Families Numbel of A dul ts i l r Families Numbel of Children in Families NLrmber of Families

a.

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

17
lo

b.
c.

106 %

Explanatory Notes: Row b refers to the most recentCoC applicationfor which the programis reporting.

4.

Non-homeless persons.

This question is to be completed for Section 8 SRO projects.

were How many income-eligiblenon-homeless.persons housedby the SRO programduring the operatingyear?

5.

Age and Gender. Of thosewho ENTERED the project during the operatingyear,how many people are in the following age and gendercategories?
(from 2b. c olum n I ) Sin sle Pe rso ns b. d.
Age

Male

Female

62 and over

5 1-61 3l -50 t 8-30 [7 andunder

oz and over

Personsin Families(from 2b. columns2 & 3)

f
g

h.
t.

5l - 6l 31-50 t8 - 30
111?

k.
m.

6-12
t<

Under1

Explanat orNot es : y year.Onlyclients duringtheoperating who entered program the in and not refers onlyto Singles in Families Persons Families Thisquestion reported under Single Persons should equal the be to ofclients in can who meetthese criteria be counted thistable.Thetotalnumber under Persons Families in should equal thesumof to be reported of 1. in 2b, reported question column Thetotalnumber clients number 2b. 2 columns and3 in question 1 6 Answer questions - 10 only for participants \yho ENTERED the project during the operating year (from 2b, columns & 2). The tenn participant meansSinglesnot in FamrliesandAduits in Fanllies. It doesnot incluciechiidren or caregivers, for 7, NOTE: The total for questions, 8 and i0 below shouldbe the same;respondto eachof thosequestions all participants. Some of the questionslisted throughoutthe APR will be askinginformationfor individualswho are chronically homeless.

HUD-40118

6a. Veterans Status.A veteranis anyonewho has ever beenon activemilitary duty status.

participants veterans? Howmany were

I0

6b. Chronically homelessperson. An unaccompanied homeless individual with a disablingconditionwho has eitherbeencontinuously h^malpccr^. e ',."" ^r more OR hashad at leastfour (4) episodes ofhomelessness the past three(3) years. To be considered in chronicallyhomeless aperson must havebeenon the streets in an emergency shelter(i.e. not transitional or housing)during thesestays. For further discussionof the definition of chronic homelessness, Other Key Definitions under the Generallnstructions see ab ove. How many participants were chronically homelessindividuals? | , I

'l,
a.

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

b.

Explanatory Notes: Each participantshouldbe listed in onllzone catesory. The total number of parlicipantsin this table shouldequalthe number of participants in question2b, colururs I and2.

8.
a.

Race. How many participantsare in the following racial categories? American Indian/Alaskan Native
Aslan

b. c. d. f
g.

Black/African American Native Hawaiian/OtherPacific Islander

Whlte
American Indian/Alaskan Native & White Asian & White Black/African An.rerican& White American I ndi anlA Iaskarr ative & B Iacl</African N American Other MultiRacial

Explanatory Notes: Each participantshould be listed in onl:l one catesory. A participantwhose race doesnot correspond categories throughi shouldbe to a countedin i. Other Multi Racial. The total number of participants this table should equal the numberof parlicipantsin question2b, in colunrns1 and 2. If using HMIS data,you may combineHMIS race response categories generate APR response to the categories.

9a. Special Needs. How many participantshavethe following? Participants may have more than one. If so, count thenr in ALL applicablecategories.For eachcondition, also indicatethe number that were chronically homeless. All
a.

Chronic

b.
c

d. f.
g

Mental illness Alcohol abuse Drue abuse HIV/AIDS and relateddiseases

1 1
1

Develoomental disabilitv
Physicaldisabilitv Domestic violence Other (pleasespecify)

h.

9b. How many of rhepanicipants disabled? l-_l arc I

Explanatory Notes; To determine whichparticipants meetHIID's definition "disabled," "Disabling of see Condition" under KeyDefinitions theGeneral Other in Instructions.

10

HUD-40118

project? (For each slept in the following placesin the week prior to enteringthe 10. prior Living Situation. How many participants 2b' number of parlicipantsin ciuestion the participant. chooseone place. The total numberof participantsin the "All; column should equal in the following places (Chooseone) pafiicipantsslept chronically homeless columnsI and 2). Also, indicatehow n.rany All I Chronic

a.

b.
c.

park, car,bus station,etc.) Non-housine(street. Emergencv shelter persons Transitional housinsfor homeless Psvchiatric lacilitv* treatmentfacility* Substance abuse Hospltal* Jail/prison* violence Domestic sifuation Livins with relatives/friends Rentalhousine Other (pleasespecify)

d. e. f
o

h
l.

rii;l:i:,] !

1.
l.

*'lfa participantcamefrom an institution (psychiatricfacility, substance therelessthan abusetreatmentfacility, hospital, orjail), but r.vas in shelterbefore enteringthe treatmentfacility, he/sheshouldbe cour.rted either the 30 days and was living on the streetor in emergency es strcet shelter or category, appropriate.

Compiete questions 11 - 15 for all participants who LEFT during the operating year (from 2c, columns I and 2). The terrn parlicipant means single persons and adults in families. It does not include children or caregivers. The tetm chronically homeless.person means an unaccompanied homeless individual with a disabling condition who has either been continuously homeless for a year or more OR has had at least four (4) episodes of homelessnessin the past three (3) years. To be considered chronically homeiess a person must have been on the streets or in an emergency shelter (i.e. not transitional housing) during these stays.

who LEFT during the operatingyear,how 11. Amount and Source of Monthly Income at ENTRY and at EXIT. Of thoseparticipants were at eachmonthly income level and with eachsourceof income? Also, pleaseplace the monthly income level many participants and eachsourceofincome for chronically homelesspersonsin the secondcolumn ofeach chart. The number ofparticipantsin Chart A and B shouldbe the same. AII Chronic AII Clronic

A. MonthlyIncome at ENTRY
a.

Sources ENTRY At C. Income

Security Income(SSI) Supplemental b. c. d
z
Z

No ncoffte

b. c. d.

s1 50
$15

Social SecurityDisability Income (SSDI) Social Securty GeneralPublic Assistance Temporary Aid to Needy Families (TANF) Program (SCHIP) StateChildren's Health Insurance Veterans Benefits EmployrnentIncome Benefits Unemployrnent

s250

$25 $5 0 0 s50 - $ 1 ,0 0 0 $1 $1001- 5 0 0 $1501- 0 0 0 $2 + $2001

f
g

f
g

h.

h.

J.

VeteransHealth Care Medicaid Food Stamps

k.
m.. n,

specify) Other(please Resources No Financial

1l

HUD-40118

AII
B. Monthly Income at EXIT No income

Chronic
D. Income Sources EXIT at
a.

All

Chruic

a.

Supplemental SecurityIncome (SSI)

b.
c

S 1 150 s l51 - $ 2 5 0

b.
c.

Social Security Disability (SSDI) Income

SocialSecurity

d
e.

s251$500 s50r s1,000 $100i- 1 5 0 0 $ $1501- 0 0 0 s2 + $2001

d
2 z

General Public Assistance Temporary to Needy Aid (TANF) Fanrilies

program(SCHIpj State Children's HealthInsurance Veterans Benefits EmploymcntIncome Unemploynent Benefits Veterans Health Care Medicaid Food Stamps

f,
o

h.

h.
I

J
l.

m. n.

Other (pleasespecify) No FinancialResources

E xp lan ato rl,n\o tes : T able A: Mo ici (i.e.,on the program entry date or as close as possibleto that day) You shouldnot report on incomereceived beforeenteringthe programor inconrereceived duling the programstay. Table B: Monthlv incorne- elit refersto the participant,smonthly income on at heisheleft the proeram(i.e., on the program exit date the_da), or as close as possibleto that day). You shouldnot report on incomereceivedd;t.g th. pr"t;;tTable C: Incomesourcesat gnlrv r-efers the particioant'ssources incomeon to of lhe dall he/sheenteredth e prosrrm (i. e., on the program entry dale or as closeas possibleto that day). You shouldnot repod * ro*..r of income t.*i*o u.r*. enteringthe prograrnor income receivcdduring the program stay. Participants with no incomeai the time of programentry shouldbe reportedin category n, No Financial Rcsources. T able D: (i.e., on the progran.r exit date or as closeas possibleto that day). You shouldnot report on sources incomer.Eiu.a of a*,qg tl* programstay. Participants with no lncomeat the time of prograrnexit shouldbe repo'ted in categoryn, No FinancialResources.

I 2a. Of thoseparticipantswho LEFT during the operatingyear (fi.om2c, colunms 1 and 2), horv many were in the projectfor the follou,ine lengthsof time? Also, pleaseplacethe length of stay for chronically homeless persons who LEFT duringthe operating year in the second coluntn. All
a.

Chronic

b.
c. d.

Lessthan I month I to 2 rnonths 3 - 6 months 7 rnonths- 12 rnonths

13months 24 months f.
o

2 5mo nths - 3y ear s :[,ears - 5 years 6yea rs- Zy ear s

h.

8 years 10years O','erl0 years Explanatory Notes: com pu tee achp articipant ' s lengt hof s t ay us ingt hepar t i c i p a n t 's p r o g r a m c n r r y d a t e a n d p r o g r a m e x i t d a t e . I f t h e p a r t i c i p a n t h aso n l yo n e progralx exit dateduring the operatingyear,calculatelength ofstay by subtraciing the programentry date fi.omthe progranrexit date. Ifthe 12 HUD_401 18

(bv tubtt.uttinqth" year.calgul?ie length ofstaY fot euth ptogtu- ttuv our,i.ioun, hu, n-,ultiol.oro*urn exit datesdurins the operatine Jhe lenqth of stay. Each and add them togetherto producea currlulative ,a nr^ffiem evit rtaiefn'. "u"1l*u-itavt

ory.Thetotal numberofparti ci pantsi nthefi rstco lum n( . . A11, , ) shou1d

1 2c' in of equal number participants question columns and2' the

1 and 2), how l2b. Length of Stay in program. For thoseparlicipantswho did NOT LEA\IE during the operatingyear (from 2d, columns project? Also, pleaseplace the length of stayfor chronically homelesspersonsrvho did NOT LEAVE long have they beeninlhe column year in the second during the operating All
a.

Chronic

b. c
d.

e i
g

h.
l.

Lessthan 1 month 1 to 2 months 3 - 6 months 7 months- 12 months 13 months- 24 months 25 mon t hs - 3y ear s 4 ye ars- 5y ear s 6vea rs - Tv ear s 8 vears- 10 vears Over 10 vears

4 6
-f

2
I

6 3 2 1

Explanatory Notes: Compute eachparticipant'slength of stay using the parlicipant'sprogramentry date and the last day ofthe operatingyear' To calculate with only one length ofstay, subtractthe programentry date from the last day ofthe operatingyear. Each participant should be associated The total nunrberof participantsin the first column ("A11")should equalthe number of parlicipantsin question2d, length of stay category. columns I and 2.

13. Reasonslbr Leaving. Of thoseparticipantswho !pE! the project during the operatingyear (from 2c, columns 1 and2S,howmany left for the following reasons?If a participant left for multiple reasons,incluile oalythe primury reason. The total numberof place the in participantsin the first column ("A11")should equal the numberof participants question2c, colurrns 1 and2. Also, please primary reasonfor chronically homelesspersons who LEFT the project during the operatingyear in the secondcolumn. All Left for a housing oppofiunity before completing program b
c.

Chronic

Completed program Non-payment of renVoccupancycharge with proj ect Non-compliance Criminal activity / destructionof property / vioience

in timeallowed proiect maximum Reached

Needscould not be met by project with ru Ies/persons Disagrecrncnt Death Other (pleasespecify)- Other housing opportunity Unknorm/disappeared
1

c.
h.
I

J
L

1 I

i3

I-{UD-40118

14. Destination. f id u ri n g th e o p e ra trn g y e a I(fro m2c,co1umns1and2),how many1eftforthefol Iowyearin thesecond f i ng who LEFT duringtheoperating persons homeiess of the place destiiation chronically destination?Also,please column.

All

Chronic

PERMANENT (a-h)

a.

(no subsidy) Rentalhouse or apartment

b. c. d.

Housing Public
8 Section Plus Cate Shelter houseor apartment HOME subsidized houseor apartment Other subsidized Homeownership Moved in with family or lliends persons Transitionalhousing for homeless Moved in with family or friends hospital Psychiatric Inpatient alcohol or other drug treatmentfacility

f.

c.
h.

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

k.
m

Jail/prison shelter Emergency housing supportive Other

Placesnot meant for human habitation(e.g. street) Other (pleasespecify) Unknown 1

(N) SHELTER EMERGENCY

OTHER (o-q)

o.

p,
q

UNKNOWN

Explanatory Notes: combine categolies provided.The response upon leavingthe programusing the categories laentify eachparticipant'sdestination ,,destination" etc.). transitional, etc.) and "tenure" (e g., permanent, public housing,homeownership, (e.g.,rental houseor apartment, categories before and be sureto look at all ofthe response response, most appropriate the Considerboth destinationand tenureto determine category. The table below providesa brief descriptionof eachresponse making a selection. participantis Enter the number of participantsunder eachdestinationcategoryin either the first column of the table or in both columnsif the in Only one reasonfor leaving shouldbe recordedper parlicipant.The total number of participants the first column homeless-. chronically 1 and 2. in i,,ett'1 shoutdequalthe number of participants question2c, columns

T
Permanent

Destination
(no Rentalhouseor apartment subsidv) Publichousing 8 Section ShelterPlus Care houseor HOME subsidized aDartment houseor apartment Other subsidized

Description Participantis moving to an apartmentor housewithout any subsidy. Participantis moving to a public housing unil Participantwill use a housingchoice voucher(formerly known asa Section8 voucher)to rent a house or apartment. Participantis moving to a unit funded by the ShelterPlus Care Drosram(e.s..TBA. SRA. PRA. Section8 SRO). providedby the Participantis moving to a unit with rental assistance assistance). or HOME program(tenant-based project-based by Participantis moving to a unit subsidized someprogramotherthan public housing,housing choicevoucherprogram(fomerly Section8), SheiterPlus Care,or HOME. h s P a r t i c i p a ni t m o v i n gt o a u n i t t h a th e / s h e a sp u r c h a s e d . to Participantis moving in with family or friends and expects live there for 90 days or more. housing Participantis moving into a unit funded by a transrtional people(e.g.,transitional housingfundedthrough progam for homeless the SupportiveHousing Program). to Participantis moving in with family or friends and expects live there lessthan 90 days.

d.

f.

h. Transitional

Homeownership Moved in with family or friends Transitionalhousing for homeless people

J Institution
l.

Moved in with family or friends

hospital Psvchiatric

hospital. to is Participant moving a psychiatric

l4

HUD-401 18

Tenu r e

L
m Emergency Shelter Other
n.

Destination Inpatientalcohol or other drug ffeatment facllify

Description

facility. or alcohol drugfieatment to t earticrpatis moving an inpatient

Participantis moving to a iail or prison. people shelterfor homeless Participantis moving to an emergency Participantis moving into supportivehousingthat doesnot correspond (a-h) and is not transitional housing categories to any of the pennanent people(i), suchas Section81t housing.* housinsfor homeless Participantis moving to a place not meantfor human habitation,such buildine. as a car. oark. sidewalk.or abandoned to Participantis moving to a place that doesnot correspond any ofthe catesories above(a-p). categoryshouldbe usedifyou are unsureaboutwhere This response and the participantis moving or ifthe participanthas disappeared there is no wav to find out where he/sheis.

Jaii/Prison
Emergencyshelter Other supportivehousing

o.

p.
q. Unl<nown
t

Placesnot meantfor human habitation Other (pleasespecify) Unknown

*HLID enconrages category.Progranrssltould report progt.amsto linit the use of the "Other SupportiveHousing" APR response destittatiotrs to housing that are pennanent or transitional in APR categories (a) through (lt) or in.categories (i) tltrough Q), respectit,ely. Exits to emergencyshelters should be reported in category (n).

the who LEFT during the operatingyear (from 2, columns 1 and 2), how many received 15. Supportive Services. Of thoseparticipants receivedfor chronically during their time in the project? Also, pleaseplacethe supportiveservices following supportiveservices homelessparticipantswho LEFT during the operatingyear in the secondcolumn. Pafticipants mav have received multiple services and ALL servicesshould be reported in the table. All
a.

Chronic
z

Outreach Casemanagement Life skills (outsideof casemanagement) Alcohol or drug abuseservices Mental health services

z z

b c. d

f.
g

services HIV/A I DS-related Other health care services Education Housing placement Employanentassistance Child care Transporlation Legal

h.
I

j
1,

1
m

specify) Other(please

i5

HUD-401 8 1

Technical objectivesfor this operatingyear (from your application' list 16. Overall prosram Goals. Under objectives, your measurable in your progress meetingthe objectives,and describe Under Progress, or Submission, ApR) for eachofthe threegoalslisted belorv. objectivesduring this operatingyear. Under Next operating Year's to (with calculation) any rreasurable provide a progess percentage for objectives the next operatingyear' bbjectives,specifythe measurable a, Residential Stability - SeeAttachment 1 Objectives:

Progress:

Ne xt Ope ratin g Year ' sO bjec t r v es :

b.

IncreasedSkills or Income - SeeAttachment I Objectives:

Progress:

Next OpcratingYear's Objectives:

Greater Self-determination- SeeAttachment 1 Objectives:

Progress:

Next OperatingYear's Objectives:

projects do 17. Beds. SHP recipientsanswer17a. S+C recipientsanswer17b. SRO recipientsanswer17c. (^111P-.SSO

not cotnpletethis question)

a. SHP. How many bedswere includedin the applicationapprovedfor this projectunder 'Curent Level' and under 'New Effort'? year? How many of theseNew Effort bedswere actually in place at the end of the operating New Effort in Place Cunent Level New Effot-t Nu nrb er Beds : of with project funds at the end of the operatingyear? S+C. How many beds and dwelling units were being assisted (lnclude bedsfor all par-ticipants, other family members,and care givers.) 17 Numb ero f Beds : Numb el o f DwellingUnr t s : 17 c. at SRO. Horv many dwelling units were being assisted the end of the operatingyear? persons who qualifyfor assistance.) (Includeunits occupied "in place"non-homeless by Numberof Dwelline Units:

b.

lo

IJUD.4O 18 1

Part II: Financial Information

18. SupportiveServices. rvasspentduring For Supportive Housins (SIIp), this exhibit providesinformationto H{jD on how SHP funding for suppoltiveservices the operating year. Enter the amount of SHP funding spenton thesesupportiveservices.IncludeHMIS costsunder "Other". from match requirement. Specifvthe value of supportiveservices For Shelter Plus Care (S+C), this exhibit tracksthe supportiveservices persons shouldkeep receivedduring the operating vear. (S+C erantees all sources that can be countedas match that all homeless on docunrentation file. including source,amount.and [.pe ofsupportive services.) For &4!gg-.1!f\1], operatingyear. receivedby homelesspersonsduring the this exhibit provides informationto HLID sn the value of supportiveservices

SupportiveServices
a. b c.

Dollars

Outreach Casemanagement Life skills (outsideof casemanagement) Alcohol and drug abuseservices Mental health services

$48,265.00 $20,278.00

$8,393.84 .49 $ 16,86'1

AIDS-relatedservices Other health cate services

h.

Education Housingplacement

Employrnentassistance Child care Transportatron

k.

m. n.

Legal Other (pleasespecify)

Food Supplemental ActivityExpenses Program

o.

$51,335.00 $759.00
$145,892.33

TOTAL (Sum of a through n)

amount of match provided to date for the Cun-rulative Shelter PIus Care Program under this grant

t7

H U D - 4 01 8 1

Operating Costs'HMIS Activitiesand Administration 19. SupportiveHousing Program: Leasing,SupportiveServices, E^. expansion "^+l-^.,^^For^"'.onc inn hese
f^" rh^ C^^lt;,., ..11^T1l:itt:"t:: ^.l,lirinp3l *: only facility, thp nennle and f..-^*l:r,,-^. homeless ^.tU of ji::::]:t grant tu,lOlli. ro,ttr. expansiona pre-existing tf projects: SHp t::0,::11 ^ ,. of Documentation resourc-es-usqd J9qL,r.il-e-dlo-bs is--4-Q!

ivins fu

amendments. or application anygrant as may expansion beincluded, in theoriginal

made lnspectionbv HLID and Auditors. Do not includeany expenditures subminedwith this report but shouldbe kept on file for possibie beforethe SHP crantwas executed year fot eachactivity during the operating Summary of Expenditures. Enter the amountof SHP grant fundsand cashmatch expended as s e r v i c e so t a ls h o u l dbe the same the SHP supportive t This table shouldadd up both horizontally and v er t ic al l y .T h e S H Ps u p p o r t i v e 18. services in u estion Total Expenditures

SupportiveServices OperatingCosts HMIS Activities Administration

No t e : P a l n n e n t s o f p rin cip a la n d in te r e sto n a n ylo a n o r m o r tgagemaynotbeshow nasanoperati ngexpense,

Sourcesof Cash Match. Enter the sources cashidentifiedin the Cash Match column, above,in the following categories.Use additional of sheets. necessarv. as

Amount
a.

Grantee/project sponsorcash Local government(pleasespecify)

c.

Stategovemment (pleasespecify)

d.

Federalgovemment(pleasespecify) Block Grant (CDBG) Community Developrnent

(pleasespecify) Foundations

(pleasespecify) Privatecashresources

c
h

f ) nn"no. n' r

r lno r a p

/ fpa<

Total

t8

IruD-4O1 l8

and New Construction 20. SupportiveHousing Program: Acquisition,Rehabilitation, charts theyearoneAPR in must these or rehabilitation. newconstruction complete that SHPfundsfor acquisition. All erantees received equally match amount SHPfunds of cash at least to the enough has to will demonstrate HLIDthatthegrantee contributed onlv. Thisexhibit wereprovided not required be submitted is to that Documentation matchingfunds or rehabilitation, newconstruction. spent acquisition, for inspection HUDandAuditors. wiLh reDort should keoton file for possible this bur be bv year duringtheoperating for each activity. match expended Entertheamount SHPgrantfunds cash of and Summaryof Expenditures.
SHP Funds
2

Cash Match

Total Expenditures

Acquisition

b.
c.

Rehabilitation
New construction Total

d.

Cash Match. Enterthe sources cashidentified in the CashMatch column, above,in the following categories. Use of additional sheets, necessary. as

Amount
a. Grantee/project sponsorcash

b.

(please Localgovernment specify)

Stategovemment(pleasespecify)

d.

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

(please Foundations specify)

(pleasespecify) Private cashresources

Occupancycharge/fees Total

h.

I9

HUD-40118

FOR HMIS ACTIWTIES O]YLY

21. For SupportiveHousine (SHP) - HMIS Activities This exhibitprovides information HIJD on how SHP-HMISfundinefor supportive to servlces rvasspentduring the operating)rear. [n1sr the amountof SHP-HMISfundingspenton theseactivrttes.

HMIS Activities Onlv

Dollars
-;,.1 iii-::..:.,
:1, . :.

E'
Cenh'aiServer(s)

ent

PersonaiConrputersand Printers Networking

Securiry
Subtotsl

.Software
Software/ User Licensing Software lnstallation Support and Maintenance SupportingSoftwareTools Subtotal Training by Third Parties HostLrs/ Tech-nical Services Programming: Customization Programming: SystemInterface Programrning: Data Conversron SecurifyAssessment Setup and On-line Corurectiviry (IntemetAcc.ess) Facilitation Disasterand Recovery Subtotal

Personnel

Project Management Coordination / Data Analysis Programming TechnicalAssistance and Trainins Administrative Support Staff Subtotal

HMIS und SpaceCosts OperationalCosts

Total

20

HUD-40118

Describeany problems and/or changesimplemented during the operating year.

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

21

HUD-40118

Repod PersonsServedWorksheet - HUD Annual Progress

Collectionof the protectedpersonalInformation(PPI) on this forrn is donewith the knowiedgeor consentof the clients. The PPI is only usedfor the following pulpose: Progtanr. in Report (APR) for the Continuumof Care(CoC) HomelessAssistance Accuratecompletionof the Annual Progress which the client is enro11ed. Progress Report. Instructions and the needed complete Annual to infonnation to is and Thisworksheet optional is intended helpyou coilect to Codes follow. Do not submitthis worksheet HUD.
Relationship Nun-rberof Months in
D f^ i a ^ f 1 ^ r l ^ r 'l 4 fF\

12a

Number of Months in Project Participant di d not l eave (calculate) t2b

New Palticipant (Y /N )

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

4

PersonsServedWorksheet (continued)
Information(PPI) on this form is donewith the knowledgeor consentof the clients. The Collection of the ProtectedPersonal PPI is only used for the following pulpose: Report (APR) for the Continuumof Care(CoC) HomelessAssistance Programin Accuratecompletionof the Annual Progress which the clieni is enrolled.

Do not submit this worksheetto HUD

No Veterans Status(Y,4'J) 6a Chronically Homeless
Fthnicin,

(Y.A{) 6b

(code) '7

Race (code) 8

SpeciaiNeeds (code) 9a

SpecialNeeds (code) 9b

Pr-ior
T ivino

Monthl y Income At
Pr n i e r t F'r n r ,

S i tuatron

Monthl yInc ome At ProjcctExit llb

((
I

11a

10

22

HUD.401 18

z)

HUD-40118

Persons Served Worksheet (continued) Collection theProtected of Personal Inforrnation (PPI)on thisforrnis donewith theknowledge consent theclients.The or of PPIis onlyused thefollowing for purpose: Accurate completion theAnnual (APR)for theContinuum Care of Progress (CoC)Homeless Reporl of Assistance Program in whichtheciientis enroiled.
Do not submitthisrvorksheet HUD to
Reasonfor Leaving
Pr no' am /nndet

13

Instructions and Codes for PersonsServed Worksheet T he use of th is wo r k s heet is opt ional. I t was de s i g n e d t o h elp yo u co llect inf or m at ion on par t ic ipant s n e e d e d t o comp lete the An nual Pr ogr es s Repor t . if t he w orksh ee t is up da t ed as par t ic ipant s m ov e in and m o v e out of you r p roje ct, m os t of t he inf or m at ion r equ i r e d for co mple tion will be c ont ained in t he wor k s hee t . D o not sub rnit th is wor k s heet wit h t he APR. F nr rrrn iee'c ih rr ce' , o f am ilies . HUD O nly r equi r e S reporling on th e nu m ber of c hildr en s er v ed, and t h e age a nd g en de r o f thes e c hildr en. O nly nam c , rela tio nship , d ate o f bir t h, and age on t he wor k s h e e t
"\A

n e e d t o b e c o m p l e t e d f o r c h i l d r e n . A s s i g n t h e a d u l ts a n u m b e r , b u t n o t e a c h f a m i l y m e m b e r . U s e t hi s n u m b e r t o t r a n s f e r t o t h e o t h e r p a g e s o f t h e w o r k s h e e t. B e g i n n i n g w i t h n u r n b e r 4 , t h e n u m b e r s i n t h e co l u m n s refer to the questions on the APR form. If any q u e s t i o n s a r e a n s w e r e d w i t h " O t h e r , " p l e a s e e n te r th e s p e c i f i c " O t h e r " a n s w e r f o r i n c l u s i o n i n t h e Ap R , Participant Number. This column allows you t o e i t h e r n u m b e r p a r t i c i p a n t s c o n s e c u t i v e l y o r to a s s i g n a c a s e n u m b e r . O n e n u m b e r s h o u l d be assigned to each adult.

HUD-40118

s Na m e. Nam esof p e rs o nw i l l n o t b e re p o rte dto H UD. T he us e of na m e si s fo r y o u r re c o rdk e e p i ng

conve n i e nce. R elatio nship . Ente r t he appr opr iat e r elat ions hip . E xamp les includ e: Self , Head of hous ehold, Spo u s e , child. E ntry Da te. En ter dat e par t ic ipant ent er ed t he proje ct. Usua lly th is will be t he dat e of ac t ual physical rrrove-in fo r a hous ing pr ojec t . E xit Date . Ente r d at e par t ic ipant lef t t he pr o_ie c t . Usu ally th is will be t he dat e t he par t ic ipant physically moved o ut f or a hous ing pr ojec t . Do n o t includ e a pa rticip an t wir o t em por ar ily lef t t he pr o j e c t and is expe cte d to r et ur n in les s t han 90 day s ( e.g . ,
L^--:+-l:-^+;^-\ rrvtlJttaLLLattvtt),

a. Mentai i l l ness b. A l cohol abuse c. D rug abuse d. H IV /A ID S and rel ateddi 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 numberof parti ci pants i th a disabilit y. w 10. P ri or Li vi ng S i tuati on. E nter the l ette r t hat best w descri bes herethe parti ci pantsl ept i n the week
^- i ^r^ ^- r ^.i ^^ r rL^ r rv ^.^i -!^r P'w Ju n^ - ^, i ^.fb l e

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 o n , e tc.) b. Emergency shelter c. Transitional housing for homeless persons d. Psychiatric facility* e. Substance abuse treatment facility* f. Ho spital * g. Jail/prison* h. Domestic violence situation i. Living with relative s/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 c m e r g e n c y s h e l t e r b e f o r e e n t e r i n g th e f a c i l i t y , h e / s h e s h o u l d b e c o u n t e d i n e i t h e r th e str e e t or shelter category, as appropriate. 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 t r y. E n t e r t h e a m o u n t o f g r o s s r n o n t h i y i n c o m e th e p a r t i c i p a n t i s r e c e i v i n g a t e n t r y i n t o t h e p r o j e ct. 1 1 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 lnonthly income ihe parricipant rs
r...;r'i.. r,h.^ o-iti.tLo ^"^i^^t

4.

In co me-e ligib le Non- hom eles s in SRO . The S R O p rog ram a llows 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 prio r to re habilit at ion. For SRO pr ojec t s o nly, ind ica te whet her t he par t ic ipant is an incon re-e ligib le, r r on- honr eles s per s on ( Y) or n o t (N). SHP a nd S + C pr ojec t s s hould s k ip t his i t e m .

5a. Date o f Birth . Ent er dat e of bir t h inc luding mon th, d ay, an d y ear . 5b. Ag e, En ter a ge at ent r y . 5c. Gen de r. En ter appr opr iat e let t er f or gender . M-Maie F- Fem ale. 6a. Vete ran s Statu s . I ndic at e if t he par t ic ipant i s a vete ran . Ple ase not e: A v et er an is any one w h o h as e ve r b ee n o n ac t iv e m ilit ar y dut y s t at us fo r th e Un ited States . 6b. Ch ron ica iiy ho m eles s per s on. I ndic at e t he numb er o f pa rtic ipant s t hat ar e c hr onic ally h o mel e ss. 7. Eth nicity. Enter appr opr iat e let t er f or et hni c glo up . a. H isp an ic o r Lat ino b. No n-Hispa nic or Non- Lat ino Ra ce . Ente r ap pr opr iat e I et t er f or r ac e. a. Ame rica n Ind ian or Alas k an Nat iv e b . Asia n c. Bla ck o r Afri c an- Am er ic an d . Na tive Hawa iian or O t her Pac if ic I s lander e . Wh ite f. Arne rica n Ind ian/ Alas k an Nat iv e & W hit e g. Asian & Whi t e h. Bla ck/Africa n Am er ic an & W hit e i. Ame rica n Ind ian/ Alas k an Nat iv e & Black/African Am er ic an j. Oth er Mu lti-Rac ial

8.

I l c . I n c o m e S o u r c e s R e c e i v e d a t P r o j e c t E n tr y. E n t e r a l 1 t y p e s o f a s s i s t a n c et h e p a r t i c i p a n t i s receiving at entry to the project,

a Srrnnlcmental Sccrrrifrr lnnome /S(l\

b. S oci al S ecuri tyD i sabi l i ty Insurance (SSDI )

n ennial Qon,,ritr,

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 N F) f. StateChildren's Health Insurance Program(SCHIP) g. Veterans benefits

k n. E**l^r,---+ Dllrplu)iileilr i-^ illcOlne

9a. Sp ecial Ne ed s. Ent er t he let t er ( s ) f or t he ca teg ory(ies) th at des c r ibe t he par t ic ipant ' s disab ility(ie s). ( You m ay double c ount ) .

; T r - - *^ r ^ , , *^ ^ r henefits j. Veterans Health Care k. Medicaid l. Food Stamps m. Other (please specify) n. No Financial Resources

z)

H U D - 4 01 8 1

I l d . I nc om e S our ce sR e c e i v e da t Pro j e c t E x i t. E nt er all t y pe s o f i n c o meth e p a rti c i p a n ti s r ec eiv ingat pro j e c t e x i t. (U s e c o d e sa s i n 1 1c.)

12a Le ng th in Sta y in Pr ogr am . Calc ulat ed it e m . (Se e En try Da t e and Ex it Dat e abov e. ) 12b. Le ng th of Stay in Pr ogr am . ( Par t ic ipant d i d no t le ave du ring t he oper at ing y ear . How lo n g ha ve th ey be en in t he pr ojec t ?) I 3. Re ason for Le av ing Pr oj ec t . Ent er t he pr im a r y re ason why th e par t ic ipant lef t t he pr ojec t . (Co mple te on ly f or par t ic ipant s who lef t t he p roje ct an d ar e not ex pec t ed t o r et ur n wit hin 9 0 d a ys. a . Le ft for a hous ing oppor t unit y bef or e comp letin g th e pr ogr am b . Comp lete d pr ogr am c. No n-p ayment of r ent / oc c upanc y c har ge d . Non -co mpli anc e wit h pr ojec t e . Crimin al a c t iv it y / des t r uc t ion of pr oper t y / vi o I e nce f. Rea ch ed max int um t im e allowed in pr oject g. Nee ds cou ld not be m et by pr ojec t h. Disa gre eme nt wit h r ules / per s ons i. Dea th j. Othe r (ple ase s pec if y ) k. Unkno wn/d is appear ed

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 ge 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 i. Transportation m. Legal n. Other (pleasespecify)

1 4 . Des t inat ion. En te r th e d e s ti n a ti o no fth o s e leav ing t he pr o j e c t P er m anent : (n a. Rent alh o u s eo r a p a rtme n t o s u b s i dy) b. P ublic H o u s i n g c . S ec t io n8 d. S helt e rP l u s C a re h e. HO M E s u b s i d i z e d o u s eo t a p a rtment h f . O t her s u b s i d i z e d o u s eo r a p a rtm e n t g. Hom e o w n e rs h i p h. M ov ed i n w i th fa m i l y o r fri e n d s T r a n s it i onal: p i. T r ans it i o n a lh o u s i n gfo r h o m e l e s s e rsons j. M ov ed i n w i th fa mi l y o r fri e n d s I ns t it ut ion: k . P s y c hi a tri ch o s p i ta l . l. I npat ie n ta l c o h o l o r d ru g tre a tme n tfaci l i ty m . J aillpri s o n E m er genc y : n. E m er g e n c y h e l te r s O t her : o. O t her su p p o rti v eh o u s i n g . p. P lac esn o t m e a n tfo r h u ma nh a b i ta ti on ( e. g. , s t r e e t) q. O t her ( p l e a s es p e c i fy ) Unk nown: r . Unk no w n 1 5 .S uppor t iv e S e rv i c e s . E n te r a l 1 ty p e s o f s uppor t iv es erv i c e sth e p a rti c i p a n tre c e i v e dduri ng t he t im e in t he p ro j e c t. a. O ut r ea c h
2b HUD-40118

Attachment 1 Park SPCR-MHDC/South cAo1c501048 ReportingPeriod:9/1/06-8/31/07 Residential Stability: Objective: Progress: 70% of participants remain S+C housing at leastone year. will in for Exceeded.16 19,or 84.2o/o participants of of remained S+C housing at least in for one year. NextOperating Year'sObjective: 70% of participants remain S+C housing at will in for leastone year. 35% of participants remainin S+C housingfor at leasttwo years. will Exceeded: of 19,or 63% of participants 12 remained S+C housing at least in for two years. NextOperating Year'sObjective: 35% of participants remain S+C housing at will in for leasttwo years. Objective: Progress: Objective: Progress: year. 1o0o/o participants paysomerentduringthe operaiing of will paid Achieved: of 19,or '100% participants somerentduring operating 19 of the
\/atr

NextOperating Year'sObjective: 100%of participants pay somerentduring operatrng will the

vE o r.

lncreasedSkills or lncome: part-or fulltimeemployment 25% of participants enteror continue will or program year. vocational training the during operating part-or fullProgress: Notachieved; of 19, or 16% of participants 3 enteredor continued program vocational training the operating year. time employment or during part-or full-tirne will Next Operating Year'sObjective: 25o/o participants enteror continue of program year. training the employment vocational or during operating Objective: program in 15%willeitherenteror continue an educational during operating the
vuat.

Objective:

Progress: NotAchieved: of '19,or 11% of participants 2 enteredor continued an ' program year. during operating the educational program 15%willeither enteror continue an educational in NextOperaiing Year'sObjective: year. duringthe operating '15% SSl, VA 50% willobtain/sustain 5% willobtain/sustain benefits, will GA, employment. obtain/sustain and 5% willobtain/sustain obtained sustained (Exceeded), of 19,or 0% obtained or SSI 0 Progress: 15 of 19, or 79o/o (Notachieved), of 19,or 0o/o VA 0 obtained sustained or or sustained benefits GA (Notachieved), 3 of 19,or 160/o and obtained sustained or employment (Exceeded). 50% willobtain/sustain 5% willobtain/sustain benefits SSl, VA NextOperating Year'sObjective: (if eligible), Sok obtain/sustain will employment. and Objeciive: Objective: on 50%of participants GA at theirdateof entryintothe program havemoved will if eligible obtainemployment or incomeby the end on to SSI/VA/SS/SSDI/SSA, year. of the operating

27

Progress:

Achieved: of 3, or 100%of thosewho were on GA at time of entry,movedto 3 SSI/VAJSSDI/SSA emplovmeni. or Next Operating Year'sObjective: 50% of participants GA at theirdate of entryintothe program on willhavemovedon to SSI/VAJSS/SSDI/SSA, if eligible obtain or employment income the end of the operating by year. 80% willeithersecurerepresentative payeeservices, pay renton timeon their or own. Progress: Achieved: of 19,or 100%of participants 19 haveeither secured representative payeeservices, paidrenton timeon theirown. or Next Operating Year'sObjective: B0%willeither securerepresentative payeeservices, pay or renton time on theirown, GreaterSelf-determination Objective: Progress: 35% of residents participate resident will in meetings duringthe operating year. NofAchieved.'1 19,or 5.2o/o residents participated resident of of in meetings year. duringthe operating Nexi Operating Year'sObjective: 35% of residents participate resident will in meetings duringthe year. operating Objective: 65% will participate peer/social in activities. Progress: NotAchieved. of 19,or 21% participated peer/social 4 in activities. Next Operating Year'sObjective: 65% will participate peer/social in activities. 75o/o sustainor renewcommunications friendsand/orfamilymembers. will with NotAchieved. Due to staffing shortages the operating year,therewas in inadequate data to providean accurate answerto this objective. Next Operating Year'sObjective: 75% willsustainor renewcommunications friendsand/or with familymembers. Objective: 20o/o engagein volunteer will activities. Progress: NotAchieved. 19,or 5% engaged volunteer 1of in actrvities. Nexi Operating Year'sObjective: 20% willengagein volunteer activities. Objective: Progress:

Objective:

28