HomeMy WebLinkAboutAttachment GU, S. Department of Housing
xnd Urban Development
Office of Community Planning
and Development
OMB Approval No. 2506-O 145 (exp. 1 ll_l0!2009)
ATTACHMENT G
Annual Progress Report (APR)
for
Supportive Housing Program
Shelter Plus Care
and
Section 8 Moderate Rehabilitation
for Single Room Occupancy
Dwellings (SRO) Program
form HUD-40112(08;2003)
Public reporlrn burden for this collection of information is estimated to average 33 hours per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information, This agency may no conduct or
sponsor, and a person is not required to respond to. a collection of information unless that collection displays a valid OMB control number.
General Instructions
Purpose. The Annual Progress Report (APR) tracks program progress and accomplishments in the Department's competitive
homeless assistance programs.
Filing Requirements. Recipients of HUD's homeless assistance grants must submit 2 APR'S to HUD within 90 days after
the end of each operating year. One copy of the report must be submitted to the CPD Division Director in_ the local HUD
Field Office responsible for managing the grant. The other copy must be submitted to HUD Headquarters, Department of •
Housing and Urban Development, Attn: APR Data Editor, Room 7262, 451 7`r' Strect,-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. They must submit an APR 90 days after the end of the first operating year and any year in which they use SHP
funding for leasing, supportive services, or operations. For years in which they do not receive SHP funding, they must submit
an Annual Certification 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 submitted
for each Shelter Pius Care component
For those grantees receiving an ea -tension, a separate report covering that period must be submitted (see Extension below)...
Recordkeepine. 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 information manually or to design a computerized system to
store and tabulate the information. The worksheets should not be submitted to HUD with the APR
Organization of the Report. The APR is organized in the following manner:
Part I: Project Progress. This portion of the report describes the progress in molding homeless persons to self-sufficiency,
services received,. project goals, and beds created.
Part 11: Financial Information. This portion of the report is completed by all grantees receiving funding under SHP,
S+C and SRO.
Final Assembly of Report. After the entire report is assembled, number every page sequentially. Mark any questions that
do not apply to your program with "N/A" for not applicable. (See Special Instructions for SSO Projects below.)
Definitions. The following terms are used in the APR As indicated, in some cases, terns are applied differently depending
on whether the funding is from SHP, S+C, or SRO.
Chronically homeless person — HUD defines a chronically homeless person as "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 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.
Disabling condition - HUD defines "disabling condition" as "a diagnosable substance use disorder, serious mental
illness, developmental disability, or chronic physical illness or disability, including the co -occurrence of two or more of
these conditions. A disabling condition limits an individual's ability to work or perform one or more activities of daily
livi n
Entered the program for S+C and SRO projects means when the participant starts to receive rental assistance. For
S+C, services provided prior to this point are recognized as necessary for outreach/enrollment and are eligible to count
as match.
Conn HUD-40118(08,2003)
An Extension APR applies to SHP and S+C grantees that requested and received an extension of their grant term from
the HIJD field office. The only difference between an APR for the extension period and the regular APR (besides the
amount of time covered) is the signature page. Grantees should circle "ties" to indicate the APR is for an extension
period and circle the operating year for which the report is an extension. For example, if the grantee is extending year •
3, the grantee should submit an APR as usual for year 3 and submit another APR for the extension period, indicating
the second is an extension and also circling year 3 on the signature page.
Family means a household composed of two or more related persons, at least one of «dhow is an adult. Caregivers are
not reported on in the APR.
Grantee means a direct recipient of the HUD award.
Left the program for S+C projects means 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 the program. If the person returns to S+C assisted housing after 90 days, that person is
considered anew participant. The worksheet is designed to capture this information.
Match for S+C means the value of supportive services received by participants in the S+C project which, in the
aggregate, must at Least 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 acquisition, rehabilitation, new construction, operations and
supportive services expenses.
Operating year for SHP means the date when participants begin to receive housing and/or services. The first
• operating year begins after development activities for acquisition, rehabilitation, and new construction are complete,
after a copy of the Certificate of Occupancy is sent to the local HUD office, and when the first participant is accepted
into the project. For projects without acquisition, rehabilitation, or new construction, the operating start date begins
when the grantee accepts the first participant. For S+C (SRA, PRA and TRA components), the first operating year
begins on the date HUD signs the grant agreement. For S+C/SRO and for Sec. 8 SRO, the first operating year begins
with the effective date of the Housing Assistance Payments (HAP) 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 initial grant for three years and a renewal
grant for two years would circle years I, 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 renewal grants, the grantee would begin by circling 6
on the APR cover sheet.
Participant means single persons and adults in families who received assistance during the operating year. Participant
does not include children or caregivers who live with the adults assisted..
Project Sponsor means the organization responsible for carrying out the daily operation of the project, if the
organization is an entity other than the grantee.
Special Instructions For Supportive Service Only Projects. SSO grantees should complete all questions, unless a
written agreement has been reached with the field office concerning which questions can be answered using estimates, or in
rare instances, skipped.
Below is an example of how information could be derived in a large, single -service SSO project:
A grantee/sponsor staff member could be assigned to collect information from the organizations housing the participants.
The staff person would contact these individual organizations to request information regarding the persons in that facility "
that use the service. For participants living on the street, the grantee/project sponsor may provide estimates.
. Information could be collected for each participant or for participants receiving services at a point -in -time. If estimates or
point -in -time counts are used, the method used must be described in the APR and the documentation kept on file.
form HUD-40118((08 20(13)
As with all projects fulided under HUT1's homelessness assistance grants, grantees operating SSO projects arc expected to
complete all APR questions that arc applicable to them. Note that all projects have been awarded funds as a result of
responding to the program goals of assisting homeless persons obtain/remain in permanent housing and increase their skills
and income. The APR documents their progress in meeting these goals.
In some circumstances field offices and grantees may sign a written 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 are solely devoted to street outreach and connection to housing and services are
not required to track participants beyond their contact with persons on the street. It is sugficient for these projects to enter
information on questions 1-10 (skipping questions 11-I3 and 17). Estimates for questions 5-9 arc allowed, given that
participants may be reluctant to answer personal questions.
Answering the questions will demonstrate that the grantee is serving the appropriate number of people, providing basic
demographic information for Congress, demonstrating that homeless persons are being served, demonstrating the types of
housing participants are connected to, and the type of services they are receiving.
Hotline Projects. - Hotline services are similar to outreach projects, but contact between grantee and participant is often of
very short duration - people enter and leave the program nearly simultaneously. It is sufficient for these projects to answer
questions 1-5 (skipping 4), 10, and 14-19 (skipping 17).
Projects Providing Services To Children Only. - Projects that provide child care, after school care, counseling for
children, etc, make an important contribution toward moving a family out of homelessness. While the main focus of the
project is providing services to the children, it is the adults who are reported on in questions 6-16 of the APR. Like all other
projects, this type is alsb targeted toward getting the families into housing and increasing the families' incomes.
Grantees may skip question 9; all other questions should be answered (except 17).
Transportation, Medical. Dental, and Other Single, Short -Duration Service Projects. - Some grantees provide a
single service of fairly short duration focused ONLY indirectly on assisting homeless persons to obtainlremain_ in permanent
housing and increase their skills and incomes. It is sufficient for these projects to enter information on questions 1-10 and
14-19 (question 17 may be skipped). However, with transportation services, it is unreasonable to think that someone would
have to give their age, race, and ethnicity to a bus driver to get a ride a few blocks.
For these services, provide a narrative, which gives the number of rides given during the operating year, and provides
estimates on the above statistics based on the population that utilizes the service.
Special Instructions For Safe HavenjSH) Projects. - Grantees are reminded that they are to report ONLY on
the number of participants the application was approved for (cannot exceed 25 participants),
IIomeless Management Information Systeml}IMIS) Projects.-I-IMIS grantees should fill out the cover sheet
of the APR (marking HMIS at the bottom) and Part II Financial Infomrration. The APR also has a sheet that lists HMIS
activities.
4
'form HUD-4O118i0)S;2003)
THIS PAGE - TO BE COMPLETED BY ALL GRANTEES
Grantee:
HUD Grant or Project Number:
Project Sponsor:
Project Name:
Operating Year: (Circle Uie operating year being reported on)
❑i 02 03 04 05 06 07 08 09 010
011 012 013 014 015 016 017 018 019 020
Indicate if extension: 0 Yes ❑ No
Indicate if renewal: ❑ Yes O No
Previous Grant Numbers for this project:
Reporting Period: (month/day/year)
from:
to:
Check the component for the program on which you are reporting.
Supportive Housing Program (SHP)
❑ Transitional Housing
❑ Permanent Housing for Homeless
Persons with Disabilities
❑ Safe Haven
❑ Innovative Supportive Housing
❑ Supportive Services Only
❑ HMIS
Shelter Plus Care (S+C)
Tenant -based Rental Assistance (TRA)
Sponsor -based Rental Assistance (SRA)
Project -based Rental Assistance (PRA)
Single Room Occupancy (SRO)
Section 8 Moderate
Rehabilitation
❑ Single Room Occupancy
(Sec. 8 SRO)
Sununary of the project: (One or two sentences with a description of population, number served and accomplisluneuts this operating
year)
Name l: Title of the Person who can answer questions about this report:
Phone: (include area code)
Address: Fax Number: (Include area code)
E-mail Address
I hereby certify that all the information stated herein is true and accurate.
Warning: HUD will prosecute false claims and statements. Conviction may result in criminal and/or civil penalties. (I8 U.S.C. 1001,
1010, 1012; 31 U.S.C. 3729, 38(2)
Name & Title of Authorized Grantee Official: Sibnrature & Date:
l
Name and Title of Authorized Project Sponsor Official: Sienature & Data:
form 1-IUD-40118((O5 2003)
PART I TO BE COMPLETED B 1'ALL GR4NTEES (EXCEPT HMIS)
SSO GRANTEES, PLEASE SEE SPECIAL INSTRUCTIONS ON PAGE 3 OF THE APR
Part I: Project Progress
I. Projected Level of Persons to be served at a given point in time. (from the application, SH-P'- Sec. F; SPC- Sec. D,
SRO- Sec. D)
Projected Level
Number of
Singles Not
in Families
Number of
Adults in
Families
Number of
Children
in Families
Number of
Families
a.
Persons to be served at a given point in time
Persons Served during the operating year.
I
Number of
Singles Not in
Families
Number
Number of
Adults in
Number of
Children in
Families
Number of
Families
a.
Number on the first day of the operating year
b.
Number entering program during the operating year
c.
Number who left the program during the operating year
d.
Number in the program on the last day of the operating year
.(a+b-c)=d
Project Capacity.
Number of
Singles Not in
Families
Number of
Adults in
Families
Number of
Children in
Families
Number of
Families
a.
Number on the last day (from 2d, columns I and 4)
b.
Number proposed in application (from la, columms 1 and 4)
c.
Capacity Rate (divide a by b) = %
4. Non -homeless persons. This question is to be completed for Section 8 SRO projects.
How many income -eligible non -homeless persons were housed by the SRO program during the operating year'?
5. Age and Gen der. Of those who entered the project during the operating year, how many people are in the following
age and gender categories?
Sing;1e Persons (from 2b, column I)
Acre
Male
Female
a.
62 and over
b.
51-61
c.
31-50
d.
18-30
e.
17 and under
Persons in Families (from 2b, columns 2 Si. 3).
f
62 and over
g
51-61
_
h
;1 - 50
i.
18-30
i.
1 3-7 7
k
6-12
1 I.
1-5
Itn. ' Under i
form HUD-40118((0S/2003 )
Answer questions 6 - 10 Only for participants who entered the project during the operating year (from 2b, columns 18
2). The tern participant means single persons and adults in families. It does not include children or caregivers. NOTE:
The total for questions, 7, 8 and 10 below should be the same; respond to each of those questions for all participants. Some of
the questions listed throughout the APR will be asking information for individuals who are chronically homeless.
Ga. Veterans Status. A veteran is anyone wbo has ever been on active military duty status.
How many participants were veterans?
6b. Chronically homeless person. An unaccompanied homeless individual with a disabling condition who has either been continuously
homeless for a year or more OR has had at Ieast 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.
How many participants were chronically homeless individuals?
Ethnicity. How many participants are in the following ethnic categories?
a.
b.
Hispanic or Latino
Non -Hispanic or Non -Latino
8. Race. How many participants are in the following racial categories?
a.
American IndiairlAlaskan Native
b.
Asian
c.
Black/African American
d.
Native Hawaiian/Other Pacific Islander
e.
White
f.
American Indian/Alaskan Native & White
g.
Asian & White
h.
Black/African American & White
i.
American Indian/Alaskan Native & Black/African American
i.
Other Multi -Racial
9a. Special Needs. How many participants have the following? Participants may have more than one.
If so, count them in all applicable categories. For each condition, also indicate the number
that were chronically homeless.
All
Chronic
a.
Mental illness
b.
Alcohol abuse
c.
Drug abuse
d.
HIV/AIDS and related diseases
e.
Developmental disability
f.
Physical disability
g.
Domestic violence
h.
Other (please specify)
9b. How many of the participants are disabled?
7
forrn HUO-40118((0S!2003)
10. Prior Living Situation. How many participants slept in the following places in the week prior to entering the project? (For each •
participant, Choose one place). Also, indicate how many chronically homeless participants slept in the following places. (Choose one)
All Chronic
a.
Non -housing (street, park, car, bus station, etc.)
b.
Emergency shelter
c.
Transitional housing (or homeless persbns
d.
Psychiatric facility`
e.
Substance abuse treatment facility*
f.
hospital*
g. -
Jai1/prison*
h.
Domestic violence situation
i.
Living with relatives/friends
j.
Rental housing
k.
Other (please specify)
*If a participant came from an institution but was there less than 30 days and was living on the street or in
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 left during the operating year (fi-oin 2c, columns 1 and 2). The term
participant means single persons and adults in families. It does not include children or caregivers. The term 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 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 Exit. Of those participants who left during 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 each chart. The number of participants in Chart A
and B should be the same.
All Cluunic All Chronic
A. Monthly Income at Entry
a.
No income .
b.
$1-150
c.
$151 - $250
d.
$251- S500
e.
$501 - $1,000
f
$1001-31500
g-
$1501- 32000
h.
$2001 +.t
C. Income Sources At Entry
a.
Supplemental Security Income (SSI)
b.
Social Security Disability Income (SSDI)
c.
Social Security
d.
General Public Assistance
e.
Temporary Aid to -Needy Families (TANF)
f
State Children's Health Insurance Program (SCRIP)
0
g
Veterans Benefits
h.
Employment Income
i.
Unemployment Benefits
j.
Veterans health Care
k.
Medicaid
I.
Food Stamps
ni
Other (please specify)
n.
No Financial Resources
form HUD-4011 a((0S2003)
AU Chronic
B. Monthly Income at Exit
®
No income
b.
$1-150
c.
$151 - $250
d.
e.
$501 - $1,000
f.
$1001-31500
-
g. $1501- $2000
-�
® $200I +
A11 Chronic
D. Income Sources at Exit
a.
Supplemental Security Income (SSI)
b.
Social Security Disability Income (SSD1)
-
c.
Social Security
d.
General Public Assistance
e.
Temporary Aid to Needy Families (TANF)
f.
State Children's Health hisuraince Program (SCHIP)-
g.
Veterans Benefits
h.
Employment Income
i.
Unemployment Benefits
j.
Veterans Health Care
k.
Medicaid
i.
Food Stamps
m
Other (please specify)
n.
No Financial Resources
12a. Length of Stay in Program. Of those participants who left during the operating year (from 2c, columns 1 and 2), how many were in
the project for the following lengths of time? Also, please place the length of stay for chronically homeless persons in the second
column.
All Chronic
a. 1 Less than 1 mouth
b.
1 to 2 months
c.
3 - 6 months
d.
7 months - 12 months
e.
13 months - 24 months
f
.25 months - 3 years
g.
4 years - 5 vears
h.
6 years - 7 years
i.
8 years - 10 years
1.
Over 10 years
12b. Length of Stay in Program. For those participants that did not leave during the operating year (from 2d, columns Land 2), how
long have they been in the project? Also, please place the length of stay for chronically homeless persons in the second colunm..
All Chronic
a.
Less than 1 month
b.
1 to 2 months
c.
3 - 6 months
d.
7 months - 12 months
c.
13 months - 24 months
f.
25 months - 3 years
c-
4 years - 5 years
h.
6 years - 7 years
i.
S years - 10 nears
i
Over 10 years
9
form HUD40118((0S:2O03)
13. Reasons for Leaving. Of those participants who left the project during the operating year (from 2c, columns 1 and 2), how many
left for the following reasons? If a participant left for multiple reasons, include only the primary reason. Also, please place the
primary reason for chronically homeless persons in the second column.
All Chronic
a.
Left for a housing opportunity before completing program
b.
Completed program
c.
Non-payment of rent/occupwhcy charge
d.
Non-compliance w.vith project
e.
Crirninal activity / destruction of property / violence
f.
Reached maximum tune allowed in project
;.
Needs could not be met by project
h.
Disagreement with rules/persons
i.
Death
j.
Other (please specify)
k.•
Unknown/disappeared
14. Destination. Of those participants who left during the operating year (from 2c, columns 1 and 2), how many left for
the following destination? Also, please place the destination of chronically homeless persons in the second column.
till Chron1
PERMANENT (a-h)
a.
Rental house or apartment (no subsidy)
b.
Public housing .
c.
Section 8
d.
Shelter Plus Care
e.
HOME subsidized house or apartment
f.
Other subsidized house or apartment
g.
Homeownership
h.
Moved in with family or friends
TRANSITIONAL (i j)
i.
Transitional housing for homeless persons
j.
Moved in with family or friends
INST1-TUTION (k-rn)
k.
Psychiatric hospital
I.
Inpatient alcohol or other drug treatment facility
m.
Jail/prison
EMERGENCY SHELTER (n)
n.
Emergency shelter
OTHER (o-q)
o.
Other supportive housing
p.
PIaces not meant for human habitation (e.g street)
q.
Other (please specify)
UNKNOWN
r.
Unknown
I0
c
form HUD-40118((Os/2003)
15. Supportive Services. Of those participants who icft during the operating year (from 2, coltnnns 1 and 2), how many received the
following supportive services dwing their time in the project? Also, please place the supportive services received for chronically
homeless participants who lett during the'operating year in the second column
All Chronic
a
Outreach
b.
Case management
c
Life skills (outside of case management)
d�
Alcohol or drug abuse services
e.
Mental health services
L
HIV/AIDS-related services
g_
Other health care services
h.
Education
i.
Housing placement
j. ..
Employment assistance
k.
Child care
l 1.
Transportation
m_
Legal
a.
Other (please specify)
1 1 fomr HUD-40118((O8/2003)
16. Overall Program Goals. Under objectives, list your measurable objectives for this operative year (from your application, Technical
Submission, or APR) ftor each (tithe three goals listed below. Under Progress, describe your progress in rneetin2 the objectives.
Under Next Operating Year's Objectives, specify tie measurable objectives for the next operating year.
a. Residential Stability
Objectives:
Progress:
Next Operating Year's Objectives:
Increased Skills or Income
Objectives:
Progress:
Next Operating Year's Objectives:
c. Greater Self-determination
Objectives:
Progress:
Next Operating Year's Objectives:
17. Beds. SHP recipients answer 17a. S+C recipients answer 17b. SRO recipients answer 17c. (SHP-SSO projects
do not complete this question)
e. SHP. IIow many beds were included in the application approved for this project under `Current Level' and under 'New Effort'?
How many of these New Effort beds were actually in place at the end of the operating year?
Current Level New Effort New Effort in Place
Number of Beds:
b. S+C. How many beds and dwelling units were being assisted with project funds at lc end of the operating year?
(Include beds for all participants, other family members, and care givers.)
Number of Beds: _
Number of Dwelling Units:
c. SRO. How many dwelling units were being assisted at We end of -the operating year?
(Include units occupied by "in place" non -homeless persons who qualify for assisiancc- j
Number of -Dwelling Units:
i 2 iona NUC-4011 ol(OS/'2O03)
' Part If: Financial Information
18. Supportive Services.
For Supportive Hotuinm (SHP), this exhibit provides information to HUD on how SHP funding for supportive services was spent during
the operating year. Enter the amount of SHP funding spent on these supportive services. Include 1-IMIIS costs under "Other",
For Shelter Plus Care (S+C), this exhibit tracks the supportive services match requirement. Specify the value of supportive services from
all sources that can be counted as uialch that all homeless persons received during the operating year. (S+C.o antees should keep
documentation on file, includin_ source, amount, and type of supportive services.)
For Section 8 SRO, this exhibit provides information to HUD on the value of supportive services received by homeless persons during the
operating year.
Supportive Services
Dollars
a.
Outreach
b.
Case management
c.
Life skills (outside of case management)
d.
Alcohol and drug abuse services
e.
Mental health services
f.
AIDS -related services
g.
Other health care services
h.
Education
i.
Housing placement
j.
Employment assistance
k.
Child care
1.
Transportation
m.
Legal
n.
Other (please specify)
o.
TOTAL (Sum of a through n)
Ctunulative amount of match provided to date for the
Shelter Plus Care Program under this grant
13
form HUD-40118((08/2003)
19. Supportive Housing Program: Leasing, Supportive Services, Operating Costs, HMIS Activities and
Administration
All grantees receiving funding under the Supponive Housing Program must complete these charts each operating year. For capansiou projects: if SLIP °rant funds
are for the expansion of a pre-existing homeless facility, only the people and expenditures for the additional expansion may be included, as in the original application
or any grant amendments. Documentation of resources used is not required to be submitted with this report but should be kept on fie for possible inspection by
HUD and Auditors. Do not include tuna expenditure made before the SHP v-ane was executed.
Summary of Expenditures. Enter the amount of SHP -ant funds and cash match expended during the operating year for each activity.
This table should add up both horizontally and vertically. The SHP supportive services total should be the same as the SI-I.P supportive
services In Question IS
SHP Funds
Cash Match
Total Expenditures
a.
Leasing
b.
Supportive Services
c.
Operating Costs
d.
IIMIS Activities
e.
Administration
L
Total
Note: Payments of principal and interest on any loan or mortgage may not be shown as an operating expense.
Sources of Cash Match. Enter the sources of cash identified in the Cash Match column, above, in the following
cateories. Use additional sheets, as necessary.
.Amount
a.
Grantee/project sponsor cash
b.
Local government (please specify)
c.
State government (please specify)
d.
Federal government (please specify)
Connutuuty Development Block Grant (CDBG)
e.
Foundations (please specify)
f
Private cash resources (please specify)
r ' Occupancy charge / fees
h. I Total
form HUD-40118((053003)
20. $upportive Housing Program: Acquisition, Rehabilitation, and New Construction
All grantees that received SI-IP funds for acquisition, rehabilitation, or new construction must complete these charts in the year orre APR
only. Tlus exhibit will demonstrate to I -IUD that die grantee has contributed enough cash to at least equally match the amount of SHP
funds spent for acquisition, rehabilitation, or new construction. Documentation that matching. funds were provided is not required to be
submitted with this report hut should be kept on file for possible inspection by HUD and Auditors.
Summary of Expenditures. Enter the amount of SIIP grant funds and cash match expended during the operating year for each activity.
SHP Funds
Cash Match
Total Expenditures
a.
Acquisition
b.
Rehabilitation
c.
New construction
d.
Total
Cash Match. Enter the sources of cash identified in the Cash Match column, above, in the following categories. Use
additional sheets, as necessary.
Amount
a. Grantee/project sponsor cash
b. Local government (please specify)
c. State government (please specify)
d. Federal government (please specify)
Community Development Block Grant (CDBG)
e. Foundations (please specify)
f Private cash resources (please specify)
g. Occupancy charge/ fees
h
Total
form HUD-40118((O5(2003)
FOR .HMIS A CHIMES ONLY
2]. For Supportive Housing (SHP) — HMIS Activities
This exhibit provides information to HUD on how SIfF-IBvf1S funding for supportive services was spent during the operating year.
Enter the amount of SI-II'-I-I1vIIS funding spent on these activities.
HMIS Act 'sties Only
Dollars
Equipment
Central Server(s)'
_
Personal Computers and Printers
Networking
Security
Subtotal
Software
Software! User Licensing
Software Installation
_
Support and Maintenance
Supporting Software Tools
_
Subtotal
Varvirnc
Training by Third Parties
Hosting / Tecluucal Services
Progranuning: Customization
Programming: System Interface
Programming: Data Conversion
Security Assessment and Setup
On-line Connectivity (Internet Access)
Facilitation
Disaster and Recovery
Subtotal
Personnel
Project Management / Coordination
Data Analysis
Programming
Technical Assistance and Training
Administrative Support Stag
Subtotal
HMIS Space and Operations
Space Costs
Operational Costs
Total
16
form HUD-40118t(OS/2OO )
Describe any problems and/or changes implemented during the operating year.
Technical Assistance and Recommendations
Based on your experience during the last year, are there any areas in which you need technical advice or assistance? If so, please describe.
font HUD-40118((08/2003)
Annual Certification of Continued Project Operation
Project Number:
Project Name:
Supportive I -lousing Program -
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.
I, , certify that the facility that received
assistance for acquisition, rehabilitation, or new construction from the Supportive Housing
Program has operated as a facility to assist homeless persons from to . *
I also certify that the grant is still serving number of
(ro/yr) (mo/yr)
persons at
(site address)
and all the requirements of the grant agreement are being satisfied.
(Signature)
(Till e)
Currellt Year
18
(Date of Certification)
form HUD-40118((OS _O03)
Persons Served Worksheet - HUD Annual Progress Report
I>>is workshect is optional and is intended to help you collect information needed to complete the Annual Progress Report. Instructions and Codes follow. Do not submit this worlcsheet
n 1IUD.
me
Relationship
Entry Date
Exit
Date
Number of Months in
Project (calculate)
12a
Number of Months in
Project —Participant
did not leave
(calculate)
12b
New Participant
(Y/N)
Non -Homeless (SRO
Only)
(YIN)
4
Date of Birth
5a
Age
5b
Gender
(Nf/I')
5c
•
19
1-1 J1)-•f0 t I S
Persons Served 'Worksheet (continued)
Do not submit this worksheet to "IUD
No.
Veterans
Chronically Ethnicity
Race
Special Needs
Special Needs
Prior Living
Monthly Income
Monthly Income
Income Sources
Income Sources
Status (VfN)
6a
homeless (code)
(YIN) 7
61)
(code)
8
(code)
9a
(code)
9b
Situation
(code)
10
At Project Entry
1la
At Project Exit
lib
At Entry
(code)
11c
At Exit
(code)
11d
El
I
II
ME
MIMI
20
1IUD-401 (8
Persons Served \Vorksheet (continued)
Do not submit this Nv'orl:sheet to HUD
Reason for Leaving
Program (code)
13
Supportive Services.
(code)
15
21
I HUD-401 1 S
Instructions and Codes fur Persons Served'`Vurlsheet
The use of tliis worksheet is optional. It ryas
designed to help you collect information on
participants needed to complete the Annual Progress
Report. If the worksheet is updated as participants
move in and move out of your project, most of the
information required for completion will be contained
in the worksheet, Do not submit this worksheet with
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 worksheet
need to be completed for children. Assign the adults
a number, but not each family member. Use this
number to transfer to the other pages of The
worksheet.
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" answer 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.
Name. Names of persons will not be reported to
HUD. The use of names is for your record keeping
convenience.
Relationship. Enter the appropriate relationship.
Examples include: Self, Head of household, Spouse,
Child.
Entry Date. Enter date participant entered the
project. Usually this will be the date of actual
physical move -in for a housing project.
Exit Date. Enter date participant left the project.
Usually this will be the date the participant
physically moved out for a housing project. Do not
include a participant who temporarily left the project
and is expected to return in less than 90 days (e.g
hospitalization).
4. Income -eligible Non -homeless in SRO. The
SRO
program allows assistance to units occupied by
Section 3 income -eligible persons residing at the
SRO prior to rehabilitation. For SRO projects
only_ indicate whether the participant is an
income -eligible, non -homeless person (Y) or not
(N). SHP and S+C projects should skip this item.
5a. Date of Birth. Enter date of birth including
month, day, and year.
5b. Age. Enter age at entry.
5c. Gender. Enter appropriate letter for gender.
Ivi-Male h- Female.
6a. Veterans Status. Indicate if the participant is a
_veteran. Please note: A veteran is anyone who
/WS ever been on active military duty slahis far
t l7Lc U17ited States.
6b. Chronically homeless person. Indicate the
number of participants that are chronically
homeless.
7. Ethnicity. Enter appropriate letter for ethnic
group.
a. Hispanic or Latino
b. Non -Hispanic or Non -Latino
8. Race. Enter appropriate letter for race.
a. American Indian or Alaskan Native
b. Asian
c. Black or African -American
d. Native Hawaiian or Other Pacific Islander
e. White
f. American Indian/Alaskan Native & White
g. Asian & White
h. Black/African American & White
i. American Indian/Alaskan Native &
Black/African American
j. Other Multi -Racial
9a. Special Needs. Enter the letter(s) for the
category(ies) 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. Other (please specify)
9b. Enter the number of participants with a
disability.
•
1.0. Prior Living Situation. Enter the letter that best
describes where the participant slept in the week
prior to entering the project. Do not double
count.
a. Non -housing (street, park, car, bus station, etc.)
b. Emergency shelter
c. Transitional housing for homeless persons
d. Psychiatric facility'
e. Substance abuse treatment ;facility*
f. Hospital*
g. Tail/prisons
h. Domestic violence situation
i. Living with relatives/friends
j. Rental housing
o 2 HUD-401 18
k. Other (please specify)
*If a participant came from an institution but
was there less than 30 days and was living on the
street or in an emergency shelter before entering the
facility, he/she should be counted in either the street
or shelter category, as appropriate.
Instruction Codes for Persons Served
Worksbeet (continued)
11a.Gross Monthly Income at Project Entry.
Enter the amount of gross monthly income the
participant is receiving et entry into the project.
1 lb.Gross Monthly Incotne at Project Exit. Enter
the gross monthly income the participant is
receiving when exiting the project.
1Ic.Income Sources Received at Project Entry.
Enter all types of assistance the participant is
receiving at entry to the project.
a. Supplemental Security Incoine (SSI)
b. Social Security Disability Insurance (SS.DI)
c. Social Security
d. General Public Assistance
e_ Temporary Aid Needy Families (TANF)
f. State Children's Health Insurance Program (SCHIP)
g. Veterans benefits
h. Employment income
i. Unemployment benefits
j. Veterans Health Care
k. Medicaid
1. Food Stamps
in. Other (please specify)
n. No Financial Resources
11d.Income Sources Received at Project Exit.
Enter all types of income the participant is
receiving at project exit. (Use codes as in 11c.)
12a Length in Stay in Program. Calculated item.
(See Entry Date and Exit Date above.)
12b. Length of Stay in Program. (Participant did
not leave during the operating year. How long
have they been in the project?)
13. Reason for Leaving Project. Enter the primary
reason why the participant left the project.
(Complete only for participants who left the
project and are not expected to return -within 90
days.
a. Left for a housing opportunity before
completing the program
b. Completed program
c. Non-payment of rent/occupancy charge
d. Non-compliance with project
e. Criminal activity/destruction of property/
violence
f. Reached maximum time allowed in project
g. Needs could not he met by project
h. Disagreement with rules/persons
I. Death
j. Other (please specify)
k. Unknown/disappeared
14. Destination. Eater the destination of those
leaving the project.
Permanent:
a. Rental house or apartment (no subsidy')
b. Public Housing
c. Section 8
d. Shelter Plus Care
e. HOME subsidized house or apartment
f. Other subsidized house or apartment
g. Homeownership
h. Moved in with family or friends
Transitional:
i. Transitional housing for homeless persons
j. Moved in with family .or friends
Institution:
k. Psychiatric hospital.
1. Inpatient alcohol or drug treatment facility
in. Jail/prison
Emergency:
n_ Emergency shelter
Other:
o. Other supportive housing.
p. Places not meant for, human habitation
(e.g., street)
q. Other (please specify)
Unknown:
r. Unknown
15. Supportive Services. Enter all types of
supportive services the participant received
during the time in the project.
a. Outreach
b. Case management
c. Life skills (outside of case management)
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
1. Transportation
rn. Lena]
n. Other (please specify)
HUD-4O 11 8