HomeMy WebLinkAboutExhibit 4Attachment A
QUARTERLY REPORT OF ACCOMPLISHMENTS
Project Title and Address
Activity Name and Description:
Race/Ethnicity of persons served by the Project: (Report actual YTD numbers)
# Total # Hispanic
Race
White
Black/African American
Asian
American Indian/Alaskan Native
Native Hawaiian/Other Pacific Islander
American Indian/Alaskan Native & White
Asian & White
Black/African American & White
Am. Indian/Alaskan Native & Black/African Am.
Other Multi -Racial
Asian/Pacific islander
Hispanic
TOTAL
Indicate type of projects(s) and service(s):
emergency shelter facilities
vouchers for shelters
drop -in -center
food pantry
mental health
alcohol/drug program
child care
other
•
transitional housing
outreach
soup kitchen/meal distribution
health care
HIV/AIDS services
employment
homeless prevention
(please list)
Number of People Served for each activity:
Non-residential Services:
YTD number serviced served
Residential Services:
YTD number of adults served
YTD number of children served
Total number served YTD
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Attachment A
EMERGENCY OR TRANSITIONAL SHELTERS
YTD number of individual households (singles): Total
Unaccompanied 18 and over male female
Unaccompanied under 18 male female
YTD number of family households with children headed by: Total
Single 18 and over male female
Single 18 and under male female
Two parents 18 and over
Two parents under 18
YTD number of family households with no children
EMERGENCY OR TRANSITIONAL SHELTERS
List the number of persons for each subpopulation you served. If you served
subpopulations that fit more than one category, you may place overlapping
numbers (duplicate persons) on the appropriate lines.
Chronically Homeless (Emergency shelter only):
Severely Mentally III:
Chronic Substance Abuse:
Other Disability:
Veterans:
Persons with HIV/AIDS:
Victims of Domestic Violence:
Elderly:
EMERGENCY OR TRANSITIONAL SHELTERS
YTD number served in Emergency of Transitional Shelters:
Shelter type Number of persons housed
barracks
group/large house
scattered site apartment
single family detached house
single room occupancy
mobile home/trailer
hotel/motel
other(describe)
TOTAL
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Attachment A
Detailed ESG Project Match: For reporting to HUD at the end of the year,
indicate the specific sources and amounts of matching funds for your ESG
projects:
ESG Funds $
SOURCES OF LOCAL MATCH:
Other Federal (including pass -through funds,
e.g., City CDBG, County FEMA, etc.)
$
$
State/Local Government Funding (e.g., State
Housing Trust Funds, Local Assessment, etc.)
$
$
Private (including recipient) Funding
Fund Raising/Cash $
Loans $
Building Value or Lease $
Donated Goods $
Donated Computers $
New Staff Salaries $
Volunteers ($5/hr) $
Volunteer Medical/Legal $
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