HomeMy WebLinkAboutAttachment GU. S. Department of Housing_
and Urban Development
Office of Conimunirr pJannin�,
and Dcv elcpm.nt
ONIB Appro�a] No 2506-01415 (exp. 1 ]'30 200(,1)
ATTACHMENT G
Annual Frag�-ess Report (APR)
for
Supportive Housing Program
Shelter Plus Care
and
Section I Moderate Rehabilitation
for Single Room Occupancy
Dwellings (SILO) Program
limn HU(J-401100','2(.103)
Public re•por-1mg bunieu far this uylIecuoil of Zo rTnaIjOiJ is mimated to avera-ce 3Z (lours per response, ineludu7, UK time lur rtviv wE uisuu,-tiuns, senreJun
e: fisting data sou cc;. CEt17Crim. anti n:aLi(ain n� the data necdtd, and cannletul, and reviewing JI° Collection of infonttaiion, 'this agency Inav no! conducK or
sponsor, and rt p:rsott is no: required to iespond�to, colkctiun OF inlorntation unless 111331 Col ctiun displrrs a t•aIid 01 --IB control nuwnher.
General InstrltclJOTIS
Purl)ose. The Aminal Progress Report (APR) track program progress and accomplislunents in the Department's. competitive
homeless assistance programs.
Filing Reyuiren)cnts. Recipients of HUD's homeless assistance ,rants must submit 2 A.PR'S to HUD within 90 dans after
the end of each o erntirw `,ear. One copy of the report must be submilted to the CPD Division Director in the local HUI)
Field Office responsible for managing the grant. The other copy must be submitted to HUD Headquarters; Department of
Dousing and Urban Development, Attn: APR Data Editor, Room 7262, til 7"' Strcct, SW, Washington, DC. 20410,
Failure to submit an APR will delay receiving grant funds and may result in a determination of lack of capacity for future
funding. An APR must be submitted for each operating year in which HUD funding is provided.
Grantees that received SHP funding for new construction, acquisition or rehabilitation are required to operate their facilities
for 20 years. Thcy must submit an APR 90 days after the end of the first operating year and any year in wWch they use SIP
funding for Ieilsing_ supportive services, or operations. For years in which they do not receive SHp funding they must subulii
an Annual Certirication of Continued Project Operation throughout the 20 years. The certification can be found at the back of
this APR.
A separate report must be submitted for each HUD grant received. For Shelter Plus Care, a separate .APR must be subruitted
for ca.ch Shelter Plus Care component
For those grantees receiving an exacrision, a separate report covering that period must be submitted (seeE--tension bclou)..
Record lceeping. Grantees must collect and maintain information on each participant in order to complete an APR Optional
worksheets are attached. The worksheets may be used to record inforruation manually or to design a con2puterized system to
store and tabulate the information. The t,�Torkshcets should not be submitted to HUD rlitll the APR.
Organizafion of the Report The APR is organized in the folloTiing manner.
Part I: Project Prgbress. This portion of the report describes the progress in inm-ing llonleless persons to self-suffciency;
services received,• project goals; and beds created.
Part a: Fiulancial Laforination. This portion of the report is completed by all grantees receiving fundingunder SHP
S+C and SRO.
Final kiscmhly of Report After. the entire report is assembled, number every page sequentially. Marls any questions that
do not apply to your program with "N/A" for not applicable. (See Special Instructions for SSO Projects be DW.)
Definitions. The follonzng terns are used in the APR As indicated; in some cases, semis are applied differently depending
Oil la'hedler the funding is from SHP, S+C, or SRO.
Chr011ieally honleless person —HUD defines a chronically homeless person as "an unaccompanied
homeless individual with a disabling condition who leas either been continuously homeless for a year or more OR has
had at least four (4) episodes of homelessness in the past three (3) ),cars." To be considered chronically homeless a
person must have been on the streets or in an emergency shelter (i.e.not trar:sitional housing) during dlesc s[a} s.
Utsablin� Condition - HUD defines "disabling condition" as "a draynosable. substance use disorder, scrolts I r-llt.al
illness, dcvelopmcnlal disability-, or chronic physical illness or disability, including the co-occurl-ence of ttiro or more of
these conditions. A disabling condition limits an individual's abilitt to ;rorl: or perform one or more activities of daily
lining."'
Entered the lIr o^ram for S+C and SRO projects IIiU115 )ellen the participant starts to receive rental assistance. For
STC, scn-iees provided prior to this point are rccognized els necessan for omtreach/enroilnlent and arc eligible to count
as nlalch.
form HUD-•�0118i;((IS.'=UOJ)
An Fstc•n.sion :SPR applies to SIP and S+C sranices dial requested and reccincd an c�tension of their grant tern front
the HUD field office. The on.]), difference bcmween an APR for die c:,tcnsion period and the rc_rular APR (besides the
amount of time coi-cred) is the signature p", . Grantees should circle "hes" to indicate the APR is for an e:dension
pen ud and circle IJrc op rnung ti ear for w Inch the report is an e::iension. For Mrnple, if the gr uitee is e. -;tending ti'ear
3. ih;, grantee should submit an APR as uswil for `car : and submit another APR fcr iltc e:%tcnsion .period, indicating
the second is an extension and also circlin,}?ear 3 on the sienatun, page.
Furuily means a household composed of two or mere related persons. al least one of iihom is an adult. Carcoivers are
not reported on in the APR.
Grantee means a direct recipicni of the HUD aWard.
Left the program for S+C projects nicans when the participant stops receiving rental assistance and is not expected to
return to S+C assisted housing. If the participant returns to S+C assisted housing within 90 days, the person should not
be considered as exiting from Ute program. If the person returns to S+C assisted housing after 90 days, ilial. person is
considered a new participant. The worksheet is designed to capture this information.
1Vlatcb for S+C means the value of supportive services received by participants in clic S+C project which, in the
aggregate, must at ]cast equal the value of the S+C rental assistance provided over the life of the project. For SHP,
match means cash used to provide the grantee's portion of acquisitioi> rehabilitation, new construction, operations and
supportive services e"'penes.
Operating ye.2r for SBP means the date when participants begin to receive housing and/or sen-dces. The first
operating year, begins after development activities for acquisition; rehabilitation; and new construction are complete,
after a copy of ti -it. Certificate of Occupancy is sent to the local HUD office, and when the first participant is accepted
into the project. For projects Mthout acquisition, rehabilitation, or new construction, fine operating, start date begins
when tate grantee accepts the first participant. For S+C (SRA, PRA and TRA components), the first operating year
begins on the date HTjD signs die grant agreement. Por S+C/SRO and for Sec. 8 SRO, the first operating year begins
ndth the effective date of the Housing Assistance Pay-nenis (I'LAP) Contract.
To determine Which operating year to circle on the APR cover page, begin counting from the initial grant operating
start date and include renewals grants. For example, a project receiving an iritial grant for three years and a rericival
gra17'i for m"o years would circle years 1, 2, and 3 respectively on the APR cover sheet for the initial grant and would
circle 4 and 5 respectively for the renewal grant_ For any future rarinval grants, the grantee would begin by circling 6
on the APR cover sheet.
Participant means single persons and adults in families tv'to received assistance daring the operating year. Participant
does not include children or caregivers who live with the adults assisted.,
Protect Sponsor- means the organization responsible for care -ging out tltc daily operation of the project, if the
organization is an entity, other than the arantce.
Special Instructions For Supportive Service Only Proiects. SSO grantees should complete all questions, unless a
1-I'ritlen agreement has been reached with the field office concenung tivlLicli questions can be answered using estimates, or ill
rare insUinces, skipped.
13clow is an cxarttple of tio`v information could be derived in a large. single-scMce SSO project:
A grantCC:!Sponsor staff mcnnber could be assigned to collect infor-madon from the organizations housing the participants.
The staff p rson would contact these incLividnal Organizatiorns to request informal ion regardin- ilre persons in that faciliry
01,11* use the sen�icc. For participants lMng on the street, the grantcciproject sponsor mav provide estimates.
Irtfortuation could be collected for e,ich pai-ticiparU or for p,tr(icipanis reccivin,,, scrniccs at a point -in -bine. If estirti,ttes or
point -in -tune counts are used. the nietirod used must be des:ribed in the?t F and the dcCtl]]1Cii1:ltion ];epi on file
iionil HUD--?Ui 18t(03) -'20C,3)
As ~rill) a1I projects funded under n -D's homelessness assistance `tants. --ranters operating SSC) projects arc expected to
complete 11 APR cuesuonS Ihr)t are applicable 10 them. Note that all projects have been a,vardcd twids as a result of
respondin`, to the prot-sm eoais of assistin`� banneless persons obtain/remain in permanent housin; and increase their stills
and incon;e. The _APR docurrncnts their process in rneztin U)ese o cats.
In some circumstances field of iecs and grantees rrjy sien a» •ritlen agreement concerning questions which can be answered
using estimates, or in rare instances, skipped. Below are some considerations for reporting on particular types of projects:
Outreach Only Projects. - Projects which arc solely devoted to street outreach and connection to housing and senyices are
not required to track participants beyond their contact � ith persons on the strcet. It is sufficient for these projects to enter
information on questions 1-10 (skipping questions 11-13 and 17) Estimates for questions 5-9 are allowed, given that
participants may be reluctant to answer persona] questions.
Anstivering the questions will demonstrate that the grantee is serving the appropriate number of people, providing basic
demographic information for Congress, dernonstradng ilial homeless persons are being sen�cd, demonstrating the types of
housing participants are connected to, and the type of services they are receiving.
Hotline PfOiects. - Hotline services are similar to outreach projects, but contact between grantee and participant is often of
very short duration - people enter aad leave the program nearly simultaneously. It is sufficient for these projects to aaSIV r
questions 1-5 (skipping 4)7 10, and 14-19 (skippino, 17).
Proiects Providino, Services To Childii-enOnly. - Projects that provide child care; after school care, counseling for
child.ren, etc. inake an important contribution toward moving a fanuly out of homelessness. VAWC the plain focus of the
project is proiading services to the children, it is the adults who are reported on in questions 6-16 of the APR Like all other
projects, this f Te is also targeted toward getting the families into housing and increasing the families' incomes.
Grantees ma}'sldp question 9; all other questions should be answered (except 17).
TranSDortation, Medical. Dental_, and Other Single, Short-Durntion Service Projects_ - Some grantees provide a
single service of fairly short duration focused ONLY indirectly on assisting homeless persons to obtain/rennain in permanent
housing and increase their sk7I1s and incomes_ It is sufficient for these projects to enierinformation on que-st;
Gramc:t.
Project Sponsor:
THIS P.1 GE - TO BE C01rIFLETE,0 BYALL C!Z,0'T£ES
HUD Gant or YroiC'=;I INllplOCT
Project Munt.
>peratmg Ycar: (Circle the operating year being, rcpomd on) Reliortb); PcTiod (month/da 'hear)
OI 02 03 04 05 Us 07 Os F79 Olo
[311 012 013 014 015 016 017 O1971P020
Indicatc if e\ -tension: 0 Yea L] No iron to'
Indicate if renewal: ❑ Yes 0 No
Previous GrantNtunbers for tltis project:
Check the component for the prooranr on whch you are reporiuig.
Supportive Housing Program (SHP) Shelter Plus Care (S+C)
❑ Transitional Housing
❑ Permanent Housing for E0111eIeSS
Persons with Disabilities
❑ Safe Haven
❑ Innovative Supportive Housing
❑ SUDD0I11Ve Seri 1Ce5 Only
❑ I3IvfIS
❑ Teri�wt-based Rental Assistance (TRA)
❑ Sponsor -based Rcntal Assistance (SRA)
❑ Project -based Rental ASsis=ce (PRA)
❑ Single Room Occupancy (SRO)
Section 8 Moderate
Tteh,ibihtation
❑ Single Room Occupancy
(Sec. 8 SRO)
Stunmary of the project: (One or two sentences -MUI a description of population, n:uaiber served and accotnplislunents flus operat m.
Y==
Nurse & Title of the Person who can ansiver questions about this report: Phone: (include area code)
Address: Fax Number: (urchide area code)
E-mail Address
1 hereby certify that all the information stated herein is true and accurate.
R'arninc: IILID Mill prosecute �tlse clangs and statements_ Conviction may result in criminal and/o- civil penal tics. (1S U.S.C. )001,
1010, 1012; 31 U.S.C. 3729, 3802)
N ime fi Title ol':Auibarized Gran(ee OfrciaF Si_nrature , Datc:
X
Name and Title of.0uihorized Proieci Sponsor l?tl 6:iI: Signature Pw
I HUD -'-0113 (Jnr=003)
PART I. TOB CMPLETED L'Y LL CJZ4ArTff S' (El'CF_PT H.iIISS)
SSD G.R_4 'TEES, PLE,4S'E SEE SP%'CIAL I,�'S'TRUCTIUI�'S' U;�'P.9G? 3 OF 3HEAM,
fart 1: Project Progress
J. Projected Level of Persons to be served at a given point in time. ([Tom the application, SIT'- Sec. F; SPC- Sec. D,
SRO- Sec. D)
2. Persons Served du rind the operating year.
Number of Dumber of
SviglesNet in Adults in
Fannie; + Familia
Number of
Nuinhcr of
Number of
Number of
51-61 I
Suigles Not
Adults ui
Children
Families
e.
u Fwnilies
r:unihes:
in ramilies
PCr50r15 in Families (from 2b, columns 2 & 3) I f
ProjectCdLeve]
n
51 -61
ll.
?0
a. Persons to bt served at a given point in tiine
>:.
2. Persons Served du rind the operating year.
Number of Dumber of
SviglesNet in Adults in
Fannie; + Familia
Number of
Children in
Families
Number of
I Families
a. I Number on the fust day of the operating year
b.
51-61 I
b. Number entering program daring the operating year
,) -50
EC.
d.
C. I Number who left the program during the operating year
e.
17 amt under
d. Number in the program on the last day of the operating year f
(a+b-c)=d
PCr50r15 in Families (from 2b, columns 2 & 3) I f
3. Project Capacit`
Number o; Number of Number of Number of
sing] esNot in Adults in Children in Families
Families Families Faltulies
a. I Number on the last day (from 2d, columns 1 and 4)
b. I Number proposed in application (from l a, columns 1 and 4)
c. Capacity Rate (divide a by b) = %
4. Non-borneless persons. This question is to be completed for Section S SRO projects.
How many income -eligible non -homeless persons were housed by the SRO progran durin.- the operating year?
5. Age and Gender. Of those who entered the project during the operabno year, how mary people are in the folloviang
age and gender categories?
Siar*le Persons (from 2b, column 1) —
+ /i,e I 1t441le I Female
a.
62 and over
b.
51-61 I
,) -50
EC.
d.
l S-10
e.
17 amt under
PCr50r15 in Families (from 2b, columns 2 & 3) I f
63 and over
n
51 -61
ll.
?0
>:.
i 6-12 I
I m.
(Und•�r 1 j I
Jomt HUD -4011 d((OS!'_UO?)
.Ajislwcr questions 6 -IU on j}- for participanls JI'ilo elltCrtd 1110 1lr0jeci (idiiiio iiic Oijerjiiu,- i'C:ir Jro;n column n's
The term participant means sirlgle persons and adults in families. I does not include children or care_>ivers. NOTE:
The total for quesrions, 7. 8 and J() below should be tyle same, respond to each of those questions for all participants. Sonic of
the questions listed tilrouL7hout the APit trill be asking information for individuals -who are chronic aIIN7 homeless.
Ga. Vtter-ans Sl:itus. A veteran isanvone \vho has ever been on active
jil ]hLsy'ddl;: stains.
Ho, -v many participint_s vvere veterans?
lb. ChrotlicAl' homeless Person. An Lwaccornllvlied homeless individual uvith a ihsabtuh condition who has either been contiliuoasly
hotneless for a year or more OR has had at least four (4) episodes of hollielessness ui the p�i.t ilirce (3) years. To be considered
chronically homeless a person must have been on the streets or in an emer;cncy shelter (i.e. not transitional housing)
during these stays.
Howlnaup'Participants were chronically homeless utdividuals? C]
7- Ethnicity. How many pa rticipants are in the follov6ng ethnic cale'ones?
a. I Hispanic or Latino
b. Non -Hispanic or Non -Latino
8. Race- How mary participants are in the folloti viug racial categories?
9a. Special Needs. HONv many participants have the following? Participants may have more than one.
If so, count then, in all applicable categories. For each condition, also indicate the number
that were chronically homeless.
All Chronic
alb. How mauv of [he Participanisare disabled? =
fbmiHUD-^-C1i8((o
10. Prior Living Situation. zloty tnmr) participLLnis sl_pi b] file follov.in_ places vi the weal: prior to cntnrlliL the project? (For each;
participant, Clloost' one p1aC.,7. Also; 7)) lcate hm" m:m)chronically homele.es parliciu:uhts shpt in the follov:mg plocea. (Cboos(- one)
All Chronic
'ffa participant came frorn an institution but was there less than 30 days andwas livihhg on the street or ui
emergency shelter before entering the treatment facility, he/she should be counted in either the street or shelter
category; as appropriate.
Complete questions 11 - 15 for all participants who )eft during the operating year (from 2c, columns 1 and 2). The term
participant means single persons and adults in families. It does not include children or caregivers. T1ie tens chronically
homeless person means sm unaccompanied homeless ind.Mdual with a disabling condition -who has either been continuously
homeless for a year or more OR has had at least four (4) episodes of homelessness in the past three (3) years. To be
considered chronically homeless a person, must have been on the streets or in an emergency shelter (i.e. not transitional
housing) during these stays.
11. Amount and Source of Monthly Income at Entry, and at EIIiL Of those participants who left dining the operating year, how many
participants were at each monthly income level and with each source of income? Also,.please place the monthly income level and
each source of income for chronically homeless persons in the second column of mach chart. The number ofpar6cipants in Chart A
and B should be the same.
All G"Tinic
O$253-S500
Monthly Income at Entr
come
0
X250 5500- $1,000- 5'1500-$2000+
All Cli onic
C_ Income Sources At En try
a. (Supplemeutrrl Securirylncome (SSI)
b. Social Security Disability Income (SSRI)
c. Social Security
d. General Public Jssistarce
e. Temporary Aid to Needy Familics (TANF)
f State Children's Health Insurance Progr:un (SCSI I)
Veterans Benefits
h. Lnnploymnent Income
i. Unemployment )3cnerts
Veterans Health Care
i:. 1�lcdicaid
1. I Food Stamps
'IOthcr (please spccih;)
n. No Fvrmuial Resources
fom HUD-4011o((il$.']pp, i
.411 Chronic
{ L'•. h4whtnh hhccme nl Esit
a. No income
b'1-]50
C. S'] 51 - S-250
d. S231 -S500
e. $501 - Sl,ot1U
f.
S1001 -S1500
31501-S2000
h. $2003 +
All Chrzmic
D lncorne SourC.cs at EV!t
ti. Supplcnhcnt„1 Sec;irit�' hhGontc (SSI)
U. Social Sccort�; Disat>ilinhicome (SSDi)
C. Sc>cial Sccurit}
d. Genera] P micA:sist;rnce
e. TemTx)ra y Aid to Needy Fmnilics (TA. 1F)
f. State Clnlclini's Ecatth hisurance Pra_ram (SCJ_Ul')
O'
Veterans Benefits
h. Employment lncwne
i. 1 Jnem]>)oyznen l Lcncf Ls
j, VeleransHcalthCare
k. Medicaid
1. Food stamps
m' OUhcr (please specify)
n. No FLlimicial Resources
122, Length of Stay in Program. Of those participants who left during the operating year (from 2c, colunuis 1 and 2), how many wcre in
the proeet for the following Jen-tJis of tune? Also, please place the length ofsy for chxonica)ly haraheless persons in the second
column.
All Chronic
12b. Length of Stay in Proartun. For those pariicipanLs that did not )e.n°e during the operating year (from 2d, colunuts I and 2), how
Jon; have theybecn in the project? Also, please place the length ofstzy for chronically homeless persons in the second coluMul.
c
13. Reasons for hearing,. Of those participants v. ha Iefr the project dunnc the operarirne ),ear (from 2c_ c.olu.-nns 1 and ? 1, lio-,v nam;
left for the following reasons? If a participant left for multiple reasons, irrcktde air%r the primum recswi Also, please place ;he
primon reason for chronically homeless persons in the second Wlumn.
All Chronic
a.
Leff for a housing opportunity before completur, program
b.
Completed programa
C.
Non-payanent of rent/occupmrcy charge
d.
Non-compliance yvith project
e.
I Criminal activity/ destruction of property / violence
f
I Reached maxunum time allowed in project
g.
Needs could not be met by project
h.
' Disagreement with rules/persons
i.
Death
j.
Other (please specify)
J,-
, Unknow /disappeared
14_ Destination. Of those participants who left during .the operating year (from 2c, colurmrs 1 and 2), how many left for
the follovan.- destination? Also, please place the destination of chronically bomeless persons in tie second column.
All Chronic
PERIv1ANENT (a -h)
a.
Rental house or apartment (no subsidy)
b.
Public Housing-
ousingc.
C.
Section 8
d.
Shelter Plus Care
e.
HOME subsidized house or apartment
f.
Other subsidized house or apartment
g.
I Homeownership
ILTMoved
in Varith family or friends
TRANSITIONAL (i j)
i.
Transitional housing for homeless persons
j.
Moved in with family or friends
STITUTION (k -m)
k.
Psychiatric hospital
r
L
Inpatient alcohol or other drag treatment facility {
M.,
Jail/prison
EMERGENCY SHELTER (n)
I n.
I Emergency shelter
OTHi-?R (o -q)
n.
Other supportive housing
P.
Places not meant for human habitation (e.gstreet)
q.
Other (please specify)
UNKNOWN
I r:
Uraknoe.lr
l r) form HUD-=.'�i l Eti 0Si'_OO.i 1
15. Sup po rtile sen-ices. Of those pan]o;pzusts who left during. tltc operating year Brom 2. columts 1 and ?j, how n:an the
follomw1e supponive services during dleir tiii;e in the projec ? F1so_ Ulrase pace the supponive enices received for chronically
hoonelcss particinants who Jeff dura?g the o r.r3lll1,.' ycar in Ole second colunu.
All Chronic
`vrti HULA-40118((D6:'^_Oi)�)
16 Overall P-2-jr)i G(lalt. Under objectives.list your measurable objectives for uis opsratiri_, yeai (&om your application, Teclutical
Submission, or APR) Ibr each of the three foals ]islet] below. Under Progress, describe }ourprogrCss in mee;iiiL Lhe oh_jeclives.
Under Ne•ct 0}--ratao fear's Objecti%,es, specify the mcasur.able objectives for the ncxI operating
a. ReEidentlal Stabilin,
Objectives:
Profess:
Nexl Operating Y-ar,s Objectives:
b_ Lrcrtased Skills orincomc
01;)ectives:
Progress:
Next Operating. Year's Objectives:
C. Grester Self-determination
Objectives:
Proms ess:
Neat Operating Year's Objectives:
17. Beds. SHP recipients answer 17a. S+C recipients zmswer 17b. SRO recipients aas"wtr 17c. (SHP-SSOprojects
do mot complete t1lis qu.estiotz)
ti. SHP. IIow many beds Avere included in the application approved for this project order `Current Level' and under `Nctiv Effort'?
How many of these New Effort beds were actual]), in place at the end of the operating year?
Current Level New Effort New Effort in Place
Nurnk-r of Beds: _ _
b. S C. Hou many beds Arid dwelling units were beuro assisi.ed yhith project funds at the end of tite operntuig year?
(Include beds for aII participants, other f unify meniber s; and care givers.)
Nmnb'L-r of Beds: _
Number of Dwellui� iliihs: _
c. SRO. Hero, many &N,elling units were tieing assisied at the epi of the operatic, year?
(InClllde units occupied by `iii place" non -homeless persons tvho qualilyfor assist'lute,)
Number of Dwelling Uitiis: _
1? lune HUD-40113i(li$,''(Ifi. )
Part rI: Financial Information
IF. SupportiveScnicrs.
For Sunnortive Housing (SH]'), this e>:hibit provides information to HUD un how SHP funding for supportive sen'ices u•,,s sper„ during
the operating year. Enter the amount of SHP funding spent on these supportive scn'ices. IDGILIJe I -TRIS costs under "Other".
For She)ter Plus Care (S+C), this exhibit frau}a t)te supportive services stitch requirement. Specify the value of supportive services from
all soiuces that c<vn be coutrted as match that all homeless persous received during the operating yenn (S+C o antes should }seep
dnc,imentatiou on file; includin_ source_ amount, and t)Pe of supportive services.)
For Sct:lion S SRO, this etihibit provides infomiation to HUD on Lite value ofsupporti ve semces received by homeless persons during the
operating year.
Supporti,v e Services Dollars
a. Outreach
b. Case management
C. Life skills (outside of case management)
d. Alcohol anddnig abuse services J
C- Mental health services 1
I' I
f AIDS-related services
g f Other health care services
Ii I Education
i. + Housing placement
j. Employment assistance
k. + Child care
1. �( Transportation I
M. Legal 1
II. Oft or(please specify) I
o. I TOTAL (Stun of a through n)
Cumulative amount of match provided to date for the
SheltcrPlus Care Prof=ram under this crani
13 Tom, HUD -401 I3((0S,'20 )
19. Support; c Bousino Pro, ram: Leasing, Supporti` c Sem iccs, C)peratin,- Costs, lIMIS Activiiies and
Administration
'JI ,rntaesrccas°ing limdur under the Sul?p;;vee Housing Prograin mus[ complete t!r_sc chaffs each oner_ttnc year. E or c):p:nuiuu prujncrs' lfS1IP;r1ni funds
are for th; `Y p W tiro ofa pre-c>:ivi g homeless facilil", on!v th, p_ople and e.,:pendit'ures for the additional espaasiun mac be included. as in flit original application
or any grant anicncurn-uts. Dcntimenwoun of rtsrnrrccs used i.c vo1 required u. he aubmined a i1h the, repon but should be k:p en Lle fur ; ossiblc ttspeaior, by
Hl4) m)d Audiioe;. DO not inuludc WIN esnendimre mad_• beforr dr_ SHIP r_ryrl "as exccukd.
Su1I1rna13of Expenditures. Enter itre wnoturt of SI1P rant funds and cash match c.�pendcd dttrint,' Lte operatialg ),ear for each activity.
7I1is (able should add ftp hot]) horizontally and vertically. The SI -D, supponjvc services total should be the same as the SHP supportive
services i.n oues(ion IS.
Sl -D) Funds Cash Match Total Expenditures
a. I Leasing
b. Supportive Services
C.. Operating Costs
I FMIS Activities
C. Administration
f Total 1 i
Nate: Payments of principal and inierzst on any loan or mortpagc may not be shown as an oPerffiing expense.
Sources of Cash Match. Evia the sources of cash idenfificd in the Cash Match colmnn, above, in the follovin,n
categories. Use additional sheets, as necessary.
Amouri
a- Grantee/project sponsor cash
b. Local goverrtrnent (please specify)
C. � State government (please specify)
j d. Federal government (please specify) 1 1
tt ConliZiutut_v Development Block Grant (CDBG)
I e. I Foundations (please specify) I I
I f I PrivLi(e cash resources (please specify) i
Occupancy charLe I Jccs
11. Ij To!al I
14 lona HUD -401 18((0&.'2003,)
'0. SuPPttrtive Hocsin, Pro_yam: Acquisition, Rehabilitation, and Ncvv Construction
?II grant _; lhat receivedIE
S' funds For ucouisilion, rehobil;tation, er new constnrction must comp;ele these churls iii the >ear one API)
of lv. Thi; exhibit NviIl demonstrate to HUD U)at uIc ^_values Las ennuvh cash to at Icast equally match the an)oent of SIip
Rinds spent for acquisition, relaabilitalion or lle- constriction. Documentation that ntut:9yn2 favids VXre Provided is not required tc be
Submitted �.vl th this report but should be J;epl on file for possiblc instuection by HTUD and Auditors..
Summar, of Expenditures. Enter Lhc mnoont of SI3P Bunt funds and cash match txpencled dtning Ube operating year for each activity.
SHI Fwxls Cash Match Total Expenditures
a. Acquisition
b. Rch.ubilitalion
C. New construction _
d. Tota
Cash Match. Enter the sources of cash identi.ired in the Cash Match column, above, in the following categories. Use
additional sheets, as necessary.
15
Pmn HUD-40115(tUS!°Oti?j
FOIA HMIS A CMITIES OA7LY
31. For Sit pnartivcHuusin,,(SNP)—H411S 4cti�jtite
This c>dtibil Provides infom)ation to HUE) on hUNj' Sl-Il'-jLVQS funding for suptxortive services W,1,s spent duriw, the operLiii)n1 vciin
Enter Ute anIount of SI II'-FIDflS fundvig spent on these activities.
HA11SActivitics 0771y + Dollars
Eq ur merit
Central Sencr(s)
Personal Computers and Printers
Networking
Securiiv I
S,Uhion .aal
Su ft�tare
Soffivare / User Licensing
Soft"rare In taIIation
Suppot i and Maintenance
Supporting Softci are Tools
Subtotal
Services
Training by Third Parties
Hosting / Technical Secs ices
Prograuuuin,g: Customization
Programming: System Interface
Procramrni.ngg: Data Conversion
Security= Assessment and Setup
On-line Connectivity (Internet Acccss)
Facilitation
Disasicr and Recovcry
Subtotal
.I'er;snnrzel
Project Management / Coordination
Data Analvsis
Prng ram.nting
Teciuucal Assist:�nce and Training
Administrative Support Staff
Hbl-Ig pace arrcl 0—
S
Spice Costs
Operational Costs
,Sa,btotal
Total
16 form HUD -4011 8((OS.20 )
Describe na} problews and/or changes implernenfed during the operaft ." �•cer.
Technical Assistance and Aecommendatious
Based on your experience during the last year, are there any areas in which you need iech?ncal advice or assistance? ifso, please describe.
1 7 Form HUD-40118((US;2003)
A111zwd Certrfcatioiz of 012t11%i ed Project Operatiolt
Supportive Housing Probrarn
Project Number:
Project Name:
Operating Start Date:
Grantees that received Supportive Housing Program funding for new construction, acquisition, or
rehabilitation are required to operate their facilities for 20 years.
certify that the facility that received
assistance for acgtusition, rehabilitation, or new consu-uction frolU the Supportive Housing
Prog = has operated as a facility to assist homeless persons from to
I also certify that the grant is still serving numt�er of
(MO/}'r) (I110/yr)
persons at
(site address)
and all the requirements of the gn-arnt ageeznent are bevl` satisfied.
(Si`�7a�re)
("Tit] e)
*Curren! Fear
(Date of Certification)
1 Slune FIU^u='011of(q,L'�OU3)
Per -Sons, Served Worksheet - HUD Annual Progress Report
This Worksheet is optional and is Intended to help you collect inCormation needed to coMplete the Artaunt Progress Report. instructions and Codes follow, Do not suhl}pit this mm kshea
to'IIUD.
I IUP -M) I IS
19
Persons Srl•I'ed WOH(Sheet (con(illued)
Do Ito( snlnnit this worksheet to MUD
\'+?. Veler:uts Cluonieally Ltluiicity Race Special Needs Special Needs
Clulus (1"r?d) llonreless (code) (code) (code) (code)
fa (Y.;r") 7 3 9a 9U
(h
Prior Living blanthly Income A' "l ' Inoonte
Siwmi. AL Project Enlrp At Project Eut
(code) 11a llb
10
Income Sources
At Ellin,
(codej
llc
l+�cume Soarers
At Est
(code)
1 1 d
7
111,10-401 1 S
20
L ersolls ,scrve(1 l�'orl(s)1e.el (continued)
Dn nut suhmil lliis tt111-1cshcet (o I -IU -D
1`!n• Re0501, for Leasing Destination Supportive Services No(eS
Program (code) (code) (code)
IJ 14 15
21 Ii l ID -401 IN
In.erruction.I and Codes forPcrson.s Served "Vorl:.clicet
The use of this worksheet is optional It v••as
designed to help you colJcct information on
participants needed to complete the Annuul Progress
Report. If the worJ:sliest is updated as participants
mole in and move out of your project, most of the
I nformation required for completion will be contained
in the worksheet. Do not subunit this worksheet v-,itb
the APR.
For projects that serve families, HUD only requires
reporting on the number of children served, and the
age and gender of these children. Only name,
relationship, date of birth, and age on the workshcct
need to be completed for children. Assign the adults
a number, but not each fancily member. Use this
number to transfer to the other pages of the
worksbee t.
Beginning with number 4, the numbers in the columns
refer to the questions on the APR form_ If any
questions are answered with "Other," please enter the
specific "Other" anstivcr for inclusion in. the APR -
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.
Nance. Names of persons will not be reported to
HU -D. The use of names is for your record keeping
.convenience.
Relationship. Enter the appropriat-e relationship.
Examples include: Self, Head of household, Spouse,
Child.
Entre Datc. Enter date participant entered the
project. Usually this vv ill be the date of actual
physical move -in for a housing project.
Exit Date. Enter date participant left the Project.
Usually this vvill be the date the participant
physically moved out for a }aousin� project. Do not
include a participant who temporarily Left the project
and is expected to return in less than 90 days (e.g.
hospitalization).
Jncomc-eligible Non-hunicless in SRO. The
SRO
ia. Dale of Birrlt. Enter Jatc o'i birth including
,Ponta. day, ai,d )rear.
Sh. ,4�c. Eutcr aec at cnL'y.
)c. Gender.. Enter apprc3hriatc Jct ter for 11enticr.
]�i•h4ulc P- Fenialc.
6a. Veterans Status. Indicate if the Participant is a
veteran. Pletisc )tote•: ,I voercut is unvone who
has ever been on aciive militar_t dvt), status for
the United Status.
Gb. CLronicnliy honicless person. Indicate the
number of participants that are chronically
hoaucless.
7. Lthnicity. E-ntcr appropriate letter for ethnic
group.
a. Hispanic or Latino
b. Non -Hispanic or Non -Latino
$. Rice. Enicr appropriate letter for race.
a_ American Indian or Alaskan Native
b. Asian
c. Black or African-American
d. Native lIati",aqjlan or Other Pacific Islander
e. White
f. American Indian/Alaskan Native & White
Asian & R kite
h. Black/African American & White
i. American Indian/Alaskan Native &
Blacl_/African A uerican
i. Other Multi -Racial
9a. Special Needs_ Enter the leiter(s) for the
category(its) that describe the participant's
disability(ies). (You May double count).
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. Othcr (please specify)
9b. Enter the number of participants with a
disability.
1(). Prior Living Situation. linter the letter that best
describes Where the participant sJCl) l in the week
prier to enicr11-1
V0 the project. Do riot double
count.
program allows assislnncc to traits occupied by c,
Section S income -eligible persons residing al tltc. d.
SPO prior to rehabilitation. For SP O proj'-cts e.
only, indicate whether the parlicipant is all f.
inco,ne-clit'ihle, atop -homeless person (1 j cu Pei `
(Ni. Slip and S=C projects should skit: this item. ]t.
Nun -housing (street, park, car, has station. etc
Emcr�cns�speller
Transitional ]iousina for ]tomcicss ircrsorts
Pslchjatric facility
Substance ahusc U2allne17t flCilitYx
I-Iospi tal"
Tail;priscut'
Dcmestic viol,�ncc situation
.ivin���.iiit rclatit• s,'Iricnds
Rental hnusin2
2 HUD -401 ] S
J:- Other (please specify') f. Rcachcd 1ua\ini un erne alloyed in project
e. Needs could not he met by l:ro)ect
'1f a par -ti <ipant came Crum an institution but h. Disagreement 'Aith rules/persons
upas there less than 30 days and was living on the i. Deolh
street Or in an emergency shelter before entering the j. Other (please specify)
facility, he/she should be counted in either the street k. lin):nov'n/disappeared
or shcher category, as appropriate.
Instruction Codes for Persons Served
Worksheet (continued)
l 1a.Gross Monthly Income at Project Entry.
14. Destination. Enter the destination of those
Enter the amount of gross monthly income the
leasing the project.
participant is receiving at entry into the project.
Permanent:
a. Rental house or npartment (ro subsidy)
I lb.Gross Monthly Income at Project Exit. Enter
b. Public Housing
theross monthly
g y income the participant is
c. Section 8
receiving when exiting the project.
d. Shelter Plus Care
e. HOME subsidized house or apartment
I lc_Income Sources Received at Project Entry.
f- Other subsidized house or apartment
Enter all t es of assistance the
YP participant is
g. Homeownership
receiving of entry to the project.
h. Moved in with family or friends
a. Supplemental Security Income (Ssl)
Transitional:
b_ Social Security Disability Insurance (SSRI)
i. Transitional horsing for horneless persons
C- Social Security
j. Moved in with family .or friends
d. General Public Assistance
Institution:
e_ Temporary Aid Needy Families (TANF)
k. Psychiatric hospital.
f_ State Children's Health InsurancePro�am (SC=)
I. Inpatient alcohol or drug treatment facility
�. Veterans benefits
m. Tail/prison
h. Employment income
Emergency:
i. Unemployment benefits
n. Emergency shelter
j_ Veterans Health Care
Other:
k. Medicaid
o. Other supportive housing,
1. Food Stamps
p. Places not meant for human habitation
in. Other (please specify)
street)
n. No Financial Resources
q. Other (please specify)
Ull1:nOWD:
Ild.Income Sources Received at Project Exit.
T. Unknown
.Enter all types of income the participant is
receil'ing at project exit. (Use codes as in 1 Ic.)
15. Supportive Services. Enter all types of
supportive services the participant received
12a Length in Stav in Progrnm. Calculated item.
during the time in the project.
(See Entry Date and Exit Date above.)
a. Outreach
b. Case management
12b. Length of Stay in Program. (Participant did
c. Life skills (outside of case management)
not leave during the operating year. IIow long
d..Alcohol or drug abuse services
have they been ir1 the
c. Mental health services
project?)
f 1-IIV/AIDS-related services
13. Rcason for Leaving Project. Epi er the primary
,. Othcr health care services
reason why the participant left 111c project.
h. L'ducalion
(Complete only for vvllo left the
i. Housing p avement
participants
project and are not expccied to return -within 90
l Eniploymcnt assistance
dans.
k. Child care
a. Left for a housing opportuni[� before
1. 'Transportation
completing the program
n1. Leeal
b. Completed prO�TLrr11
n. Olher(pleasc spccl Jy)
C- Non-pavmenl of ren Uoccupurlcy chorle
d. Non-compliance with project
C. Criminal uctiv iiy/destruction of property/
vio.lencc
HUD -401 I