OMB Approval 2506-0145 No. (exp.

i l/30/2009)

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

Annual ProgressReport (ApR)

for Supportive Housing Program
ShelterPIusCare and Section8 Moderate Rehabilitation for SingleRoom Occupancy Dwellings (SRO) Program

Public reporting burden for this collection ofinformation is estimatedto average 33 hoursper response, including the time for reviewing instr.uctiors, s earch i t r g e x i s t i n g d a t aso lr r ce s' g a th e r in g a n d m a in ta in in g t hedataneeded,andJompl eti ngandrevi ew i ngthecoi l e"cti onofi nformati on. Thi sag enc y rnay nor couductor sponsor,and a person is not requiredto respondto, a collection ofinformation inless that colllction oirjoy, u valid oMB controlnumber.

suD- 40118

General Instructions purpose. The Anriual progressReporl (APR) is a reporling tool that HUD usesto lrack programprogressand funding. a1d inform the Department'scompetitiveprocessfor homelessassistance "..o*plirh*ents assistance srants must submit 2 APR'S to HUD lvithin 90 davs atler of Filing Requirements.Recipients HUD's homeless be submrttedto the CommunityPlanningand Development the end of' each operatinq vear. One copy of the reportmust for nit".tot itr the loca1HUD Field Office responsible managingthe grant. The other."I-y-T":lP:sLrtnltted f CpOlp"*.tr of Housing and Urban Development,Attn: APR Data Edrtor,Room 7262, 45I l" Street, Depafiment to HUD Headquarters, DC. 20410. Failure to submit an APR will delay receivinggrant fundsand may result in a determinationof SW, Washington, lack of capacityfor future funding. An APR must be submrttedfor eachoperatingyear in which HUD funding is provided. acquisition,or rehabilitationarerequiredto operatetheir facilities that receivedSHp funding for new construction, Grantees for 20 years. They must submit an ApR 90 daysafterthe end of the first operatingyear and every year throughouttire 20 years. APR must be report must be submittedfor eachHUD grantreceived. For ShelterPlus Care(S+C),a separate A separate submittedfor eachS+C component. report covering that period must be submitted(seeExtensionbelow). receiving an extension,a separate Fol thosegrantees must collect and maintaininformation on eachparticipantin orderto completean APR. Optional Recordkeeping. Grantees worksheetsare attached. The worksheets may be usedto record information manually or to design a computerized system lo store and tabulatetlie information. The worksheetsshould not be submitted to HUD with the APR. Organization of the Report. The APR is organizedin the following manner: personsto self-sufficiency, part I: project progress. This porlion of the report describes progressin moving homeless the for beds/units. servicesreceived,listing project goals,and accounting documenting SHP, receivingfunding r"rnder part II: Financial Information. This portion of the report is completedby all grantees S+C, and SRO. that do number every pagesequentially.Mark any questions Final Assembly of Report. After the entire reporl is assembled, with "N/A" for not applicable.(SeeSpecialInstructionsfor SSO Projectsbelow.) not apply to your program type is dehnedbelow. Note that a client's client/household Deli'itions of Client/Household Types. Each clienVhousehold compositionat theprogranxentry date closestto the start ofthe the client's age and/orhousehold tlpe shouldbe basedon operatingyear. at of Families - A family is a househoidcomposed two or more relatedpersons, leastone of who is a child accompanied by an adult or a juvenile Parent. by by Singlesnot in Families - Personsnot accompanied children, including pregnantwomen not accompanied other youth present When two adultsor rlvo unaccompanied youth, are singlesnot in families. childrenand unaccompanied togetherfor services,eachperson shouldbe countedin singlesnot in families.. Clients' householdstatusshouldbe determinedbased on their household composition at the program entry date closestto the start of the operating year. This meansthat pregnant women expectedto give birth during their program stay should stil1be counted as singles not in families. of A6ults in Families - Within a family, an adult is any person 18 yearsof age or older. For the purposes APR madebased on their age and household reporling, the cieterrninationof whether a person is an adult in family should be compositionat the program enfry date closestto the start ofthe operatingyear. by Children in Farnilies - Chiidren in Families aredefined as children underthe ageof 18 accompanied one or more or guardian). Chiidren in families also include both a juvenile parentand the parent'schiid(ren). adults(parent,relative of For the purposesof ApR reporling, the determjnation whether a personis a clii1din family shouldbe madebasedon and their a_ee householdcompositionat the programentry dateclosestto the stafi of the operatingyear. For erample, (if durir]g clientswho are lessthan 18 years of age on the fi.rstday of the operathg year or at programentry they entered ofthe operatingyear. the operatingyear) shouldbe countedas childreneven ifthey rurn 18 duringthe course
HUD-101i8

Personsin Families - Persons families inciudesadultsin families and childrenin families, in

terms are applieddifferently Other Key Deiinitions. The following terms are usedin the APR. As indicated,in somecases, dependingon rvhether funding is from SHP, S+C, or SRO. the person- HUD defines chronicallyhomeless a personas "an unaccompanied Chronicaily homeless homeless individual "':+r'4 urD4urrllS LU ^rndition who haseitherbeencontinuously ^ r:^^Lrj.^^ wrlrr homeiess a yearor more OR hashad at leastfour (4) for epis odes of h o m e l e s s n e s s i n th e p a s tth ree(3)years." Tobeconsi deredchroni cal l yhomel ess,apersonm ust havebeen on the streets in an emergencyshelter(i.e., not in transitionalhousing)during thesestays. or HUD's definitionof a chronically homeiess personis basedon the following components: o Unaccompaniedhomeless individual: an unaccompanied homeless individualhasthe samecharacteristics of a Singlenot in a Family (described above). . Disabling condition: see the instructionsunder disablingcondition (below) to deierminervhether client is a disabled. Did not leave the program - This term refersto clients who were in the program on the last day of the operating year. Disabling condition - liUD definesa disablingcondition as: (1) A disability as defrnedin Section223 of the Social SecurityAct; (2) a physical,mental, or emotionalimpairment which is (a) expectedto be of long-continued and indefinite duration,(b) substantially impedesan individual's ability to live independently, and (c) of sucha naturethat such ability could be improvedby more suitablehousing conditions;(3) a developmental disability as definedin section102 of the Developmental DisabilitiesAssistanceand Bill of RrghtsAct; (4) the disease acquiredimmunodeficiency of sl,ndromeor any conditionsarising from the etiological agencyfor acquiredimmunodeficiency slndrome; or (5) a diagnosable substance abusedisorder. Entered the program - Enteredthe program refersto the first day a client receivesservices.For a residentiai program, this datewould represent first day of residence the program's housing. For services, the in this datemay represent the day of program enrollment,the day a servicewas provided, or the first date of a period of continuous participation a in service(e.g.,daily, weekly, or monthly). For S+C and SRO programs,the program entry date is the date tirat the participantstafisto receiverental assistance. For S+C, services provided prior to this point are recognizedas necessary outreach/enrollment are eligible to count as for and match. An Extension APR appliesto SHP and S+C grantees that requested and receivedan extensionof their grantterm frorn the HIID field ofhce. The only differencebetweenan APR for the extension period and the regularAPR (besides the amountof time covered)is the signaturepage. Grantees should circle "yes" to indicatethe APR is for an extension rhe operatingyear for which the reporl is an extension. For example,if tire granteeis extending year 3, -.'i^,1 "-'l ^i-^1. the granteeshould submit an APR as usual for year 3 and submit anotherAPR for the extensionperiod, indicating the secondis an extensionand also circling year 3 on the signaturepage. Grantee meansa direct recipientof the HUD award. Lelt the program - Left the program refersto the last day a client receivesservices.For a residential program,this date rvould represent last day of residencein the program's housing. For services,the exit datemay represent last day the the as er v ic er v as p ro v i d e d o rth e l a s td a te o fa p eri odofconti nuousserviIfacl i entl eavestheprogramtempor ar ily( e. g. , ce. for a hospitalization) is expectedto return within 30 days, do not count that client as havilg left the program. but For S+C programs,the program exit date refersto the date the participantstopsreceivilg rentalassistance is not and housing. If the participantreturnsto S+C assisted housingwithin 90 days,the person ^--'^t^'-{ r^ i6h''- to S+C assisted shouldnot be considered exiting from the program. If the personretums to S+C assisted as housingalter 90 days,that personis considereri neu,participant. The worksheetis designedto capturethis information. a N{atch forS+C is the valueof supportive services receivedbypanicipants inthe S+Cprojectrvhich, inthe aggregate, must at leastequal the value of the S+C rental assistance provided over the life of the project. For SHP, matchis cash rrce'l rn tt.^ grantee's portion of acquisition, new construction, rehabilitation, operations supportive and services -.n''i,'lo expenses. 3 HUD_40 118

'

activitiesfor acquisition, Operating year - For SHP programs,the first operatingyear beginsafter development reh:rhilitationand new consfuction are complete aftet a copy of the Certificateof Occupancy sentto the local HUD is , rehabilitation, L3w into the project. For projectswithout acquisition, or olfice, and when the first participantis accepted cnncfnretinnrhe 6pe13fi1g HMIS projects, the start date begins when the granteeaccepts first padicipant. For dedicated thc nneratino 'ery bsgins when any eligible cost includedin the approvedprojectbudgetis incuned. For S+C (SRA, For S+C/SRO PRA and TRA components), first operatingyearbegins on the dateHUD signsthe grantagreement. the (HAP) and for Sec.8 SRO, the first operatingyear beginswith the effectivedateof the HousingAssistance Payments Contract. To deterrnine which operatingyear to circle on the APR cover page,begin countingfrom the initial grant operatingstart dateand include renewalgrants. For example,a project receivingan initial grantfor threeyearsand a renewalgrant for on two yearswould circie years l, 2, and 3 respectively the APR cover sheetfor the initial grant and would circle 4 and 5 recneefirrelrr fls renewal grant. For any future renewaigrants,the granteewould begin by circling 6 on the APR fnr coversheet. Participants - The term participantrefers to Singlesnot in Families and Adults in Familiesas definedabove. Participrnt doesnot include children or caregiverswho live with the adultsassisted. Project Sponsor meansthe organization responsiblefor carrying out the daily operation of the project, if the organization is an entity other than the grantee.

SSOgrantees shouldcompleteall questrons, Special Instructions for Supportive Service Onlv (SSO) Programs. can unlessa written agreement been reachedwith the field office concemingwhich questions be answered has using estimates, or in rareinstances, skipped. SSO Below is an exampleof how infor:rnation could be derivedin a large,single-ser-vice project: A granteelsponsorstaff member could be assignedto coilect information from the organizationshousing the participants. The staff person would contact these individuai organizationsto requestinformation regarding the personsin that facility that use sponsormay provide estimates. the service.For participantsliving on the street,the grantee/project receivingservices at.apoint-in-time. If estimates Information could be collectedfor eachparticipantor for participants or in point-in-time countsare used,the method used must be described the APR and the documentation kept on file. grants,grantees operatingSSOprojectsare expected assistance As with all projectsfundedunder HUD's homelessness to completeall APR questions that are applicableto them. Note that all projectshavebeenawardedfundsas a resultof personsobtain/remain permanent in respondingto the program goals of assistinghomeless housingand increase their skills and income. The APR documentstheir progressin meetingthesegoals. In some circumstancesfield offices and granteesmay sign a written agreementconcerningquestionsthat can be answered using estimates, in rare instances, or skipped. Seethe specialinsffucfionsbelow for reportingon specialtypesof projects,such medical,dental,and othersingle, as outreachonly projects,projectsproviding servicesto children only, and transportation, short-duration serviceproj ects. SSO programs are a third prtority for local HMIS implementation, following emergencyshelters,transitional housing programs,outreach programs,and permanentsupportivehousingprograms. Once SSOprogramsareincludedin the HMIS, using their HMIS data. SSO grantees that arenot yet participatingin SSO grantees will be able to answerall APR questions providedabove. using the specialinstructions HMIS wili needto collect data to answer the APR questions to Outreach Only Frojects. Projectswhich are solely devotedto streetoutreachand connection housingand services are not requiredto rrack participantsbeyond their contactwith personson the street. It is sufficientfor theseprojectsto enter for questions 5-9 are allowed,given that information on questions1-10 (skipping questionsi 1-13and l7). Estimates pafiicipantsmay be reluctantto answerpersonalquestions. numberof people,providingbasic that the granteeis servingthe appropriate Answering the questions will demonstrate personsarebeing served,demonstrating types of the that homeless demographic information for Congress,demonstrating they are receiving. housingparticipantsare conaectedto, and the tlpe of services
HUD-40118

are Hotline Projects, Hotline services similar to outreach only projects, but contactbefweengranteeand participantis often ofvery short duration- peopleenterand leave the programnearly simultaneously.It is sufhcient for theseprojectsto answer questions (skipping 10,and 14-19(skipping17). 1-5 4), Projects Providing Services To Children Only. Projectsthat provide child care,after schoolcare,counseling for While the main focus of the children, etc. makean importantcontribution toward moving a family out of homelessness. project is providing services the children, it is the adultswho are reportedon in questions I 6 of the APR. Like all other to 6plojects, this rype is also targeted toward getting the famrliesinto housingand increasing families' incomes. Grantees the may (except17). skip question all otherquestions 9; shouldbe answered Transportation, Medical, Dental, and Other Single, Short-Duration Service Projects. Somegrantees provide a homeless personsto obtain/remain permanent in single serviceof fairly shorl durationfocusedONLY indirectly on assisting housingand increase their skills and incomes. It is sufficient for theseprojectsto enterinformation on questions1-10 and 14services, is unreasonable think that someone it to 19 (question17 may be skipped). However, with fransportation would have to give their age,race,and ethniciryto a bus driver to get a ride a few blocks. provide a narrative,which gives the number of rides given during the operatingyear,and providesestimates For theseservices, on the abovestatistics basedon the population that utiiizes the service. Special Instructions For Safe Haven (SH) Proiects. Crrantees shouldreport on all participantsservedduring the operatingyear. Note: this is a changefrom prior instructionswhere grantees were instructedto report on the first 25 participantsserved.

SpecialInstructions for HomelessManagementInformation Svstem(HMIS) Proiects.HMIS grantees

shor"rld out the cover sheetof the APR, Part II FinancialInformation.and the HMIS Activities section. fiil

HUD-401 18

THIS PAGE . TO BE COMPLETED BY ALL GRANTEES

urantee:

or Number: HUD Grant Project

of San Francisco Deoartment HumanServices

ProjectSponsor:

cAO18501005
ProjectName:

Catholic CYO Charities

Operating Year: (Circle the operatingyear being reportedon) (monthiday/year)

Positive Match(Ritada Cascia)

ReportingPeriod:

!r Zz tr: E+ trs no 3t xn8 tre nto ! il n 1 2n r : ! r + n rs trrofl rz l rs n rs l zo

Indicateif extension: I Yes fl No

from: Nov. 1,2006

Indicateif renewal: PreviousGrantNumbers for this proiect:

to:Oct. 31,2007 Xff ves D No

8001004 cAo1 8401 cAo1 031

Check the componentfor the programon which you are reporting.

Supportive Housing Program (SHP) ! TransitionalHousing

ShelterPlusCare (S+C) TeJrant-based RentalAssistance tr (TRA) Rental Assistance Sponsor-based n (SRA) n Project-based Rental (PRA) Assistance (SRO) Single RoomOccupancy n

Section ModerateRehabilitation 8 n Single RoomOccupancy (Sec.8 SRO)

X! Housing for Permanent Homeless Personswith

Disabilities Safe Haven n Innovative Supportive tr Housing

tr
!

Supportive Services Only HMIS

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

unitswhich are locatedat 1652 EddySt. and PositiveMatch(Ritada Cascia)Programconsistsof sevenapartment providedto 34 familiesin San Francisco. off site mobileintensive case managementservices Positive Match provides legal,housing, wrap aroundservicesto coordinate medical, benefits, comprehensive employment, needs of families. educational and psycho-social
Name & Title of the Personwho can answerquestionsabout this report: c od e ) Phone: (include area

BrianCahill,Executive Director
Ph.D.,LMFT EllenHammerle, ProoramDirector

(41s) e72-r22e
(415) 202-0933

Address: Fax Nu'rber: (include areacode)

1652EddyStreet, San Francisco, 94115 CA #8, E-nrail Address ehamm erle@cccyo. org

(4l 5) 202-0937

HUD-401l8

01r' ! E r' 2Et:tE 15: I 0

4 rE ' i l l ' :B :-i 1

F1IT* [rA Cri5a,lIA

E.J

I h er ebv c c r t iF l, th a t a l l th e i n " fo rrn a ti o r' )s l al ed herei rr i s true aud a.ccural e. lVerning;|JLlLl proecr.rto rvill 1 0 10. l0l2; il 1iS C .3 7 !9 .3 8 (n \
d l r i a mcr r f i tl c o l ',j \u th o rrzcd Gr aniec 0llicial M i l : 1 rtn g K i rn -N1 o l rn a .{-;r anlsNlllr r qr r

S i pnuprc&

l)al.

]a
jcct liptr nsnr ( ) l.ircia I N a r ne a n rJ l i rl c o l ' /\!l h ,rrizcli Pr ,.i Si anit Lrrc

* *{ ; t

l/

r z ? - a ' "}

t^zY*

Fil llt-40 il 3

(EXCEPT HMIS) BY I. PART TOBE COMPLETED ALL GRAIITEES

GK4NTEES,PLEASESEE SPECIALII'ISTRUCTIONSON PAGE 3 OF THE APR SSO

Part I: ProjectProgress
1.
C oC

(This informationcomesfrom the most recent ProjectedLevel of Personsto be served at a given point in time. lication aoolicableto this
Number of SinglesNot in Families

a.

Level Proiected to Persons be servedat a given point in time

of Number Adultsin Families

Number of Children i n Fami l i es

Nun.rberof F ami i i es

J4

5B

J4+

t.

Servedduring the operatingyear. Persons

Number of SinglesNot in Families Number of Adults in Families Number of Children in Families OU N u mber of F ami l i es

on Nun-rber the first day of the operatingyear Number enteringprogramduring the operatingyear Number who left the programduring the operatingyear Number in the programon the last day of the operatlngyear (a+b-c)=d

47

az

b.
c

28
to tro

19
42.

26
to

d.

oo

62

Explanatory notes: Types in the GeneralInstructionsaboveto determinewhich clientsshouldbe countedas SinglesNot in SeeDefinitions of Client/Household type that may in in Families,and Chiliien in Families. Note that this table does not accountfor changes client/household Families,Adults type basedon the client's age a shouldbe assigned single clienvhousehold occur duri'g the courseofthe operatingyear. Instead,eachclient only compositioni thnpio'gro* entry tlate closestIo the start ofthe operatingyear. Inthis way, eachclient is counted and/orhous-ehold once in the table. to graphic and explanations determinewho shouldbe countedin rows a-d: Use the follor.ving

Client in program on llrst day of operalingyear, left during the year: count in 2a and 2c. Client in program on lirsl day of operaling Year and last day of operaling year: count in 2a and 2d.

ard entered lefl Cli8nt g pr ogr am ing dur oPer atin in 2b and2c. Yearcount :
Client eniefed and left program before glail of operatingyear do noi count in queslion2 Client enlered program during operatingyesr and slill in program on lasl day of year couni in 2b and 2d.

First day ofthe ope.aliig year

Last day oithe operallng Year

the before first dayof the the who entered program ali year: Thisrow includes clients Numberon the I'irstday of the operating year. thefirst dayofthe operating until after the year operating anddid not leave program
b. the prograrnon or after the first Number entering the program during the operating year: This row includesall clientswho entered y.., ,ip to and including the last day of the operatingyear. For clientsrvith multiple programentry dates,use the day of the operating the ifhe/she entered Droqrammore than eniry date ciosestto the siart ofthe operatingyear.Do not count the client more than once even v on ced urin gth e oper at inq er r ' prograrnon or afterthe first day of the Number rvho left during the operating year: This row includesall clients who left the the lait day ofthe operatingyear. For clientswith multiple progranlexit dates,use the exit date operatrngyear,up to and"including

c.

l8 HUD- 40r

more than oncedurinq year.Do not countthe clientmore thanonceevenifhe/sheexitedthe progranr closest the end ofthe operating to year. the operatrnq d. l Numb erin the pr ogr am ont helas t day of t heoper a t i n g y e a r : T h r s r o w i n c l u d e s a l c l i e n t s w h o w e r e r n t h e p r o g r a m aso fth e fi r st drv nfrhe nrrerafino .,earor who entered yearundtvho did not leaveduring the opelatltg year. The numberOf during the operating year is calcuiated based the responses rows 2a through2c. For on cirents famiiiesin the program the last day ofthe operating to or on or eachcolumn,acici numberof clientsor familiesin row 2a to the numberof clients familiesin rorv 2b and subtract numberof the the clientsor familiesin row 2c. Therefore. - 2a+ 2b 2c. 2d

3.

Project Capacity.
Number of S i ngl es ot i n N Families N umberof Adults rn Fami l i es N umber of Children in Fami l i es
N u mb e r o f F a mi l i e s

a b. c.

Number on the last day (from 2d, columns 1 and 4) (from 1a,columns1 and4) Numberproposeci application in CapacityRate (divide a by b) : %

66 34.

OZ '14

o%

1823%

Explanatory Notes: Row b refers themostrecent to CoCapplication whichtheprogram reporting. for is

Non-homelesspersons. This questionis to be completedfor Section8 SRO projects.

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

5.

Age and Gender. Of thosewho ENTERED the project during the operatingyear, how many people are in the follorving age and gendercategories?
(from 2b. column 1 Sinsle Persons a.

Ase
62 and over

Male

Female

b.
c d.

51-6r
31-50 18-30
17 and under

Personsin Families (from 2b. columns2 & 3)

f.
o

62 and over

h.

J.

51 ot 31-50 18-30 I3-t7

D - tz

1 1

1
q
4A

2
2 1
.+

1 z
J

k.
m.

Under1

Explanatory Notes: Thisquestion refers only to Singles in Families Persons Families not and in who entered program the year.Oniyclients duringtheoperating who meetthese criteria be counted thistable. Thetotalnumber clients can in of reported under Single Persons should equal thenumber be to reported question column1. Thetotalnumber clients in 2b. of reported under Persons Families in should equal thesumof columns be to 2 and3 in question 2b. Answet questions - 10 only for participants rvho ENTERED the project during'the operating year (from 2b, columns1 6 & 2). The term participant meansSinglesnot in Familiesand Adults in Families. It doesnot include children or caregivers. NOTE: The total for questions, 8 and 10 below shouldbe the same;respondto eachof those questionsfor all participants. 7, Someof the qr.restions listed tlu'oughout APR lvil1 be askinginformationfor individualswho are chronically homeless. the

HUD-40r t8

6i'.

Veterans Status. A veteranis anyonewho has ever beenon activemilitary dutystatus.

were veterans? How many participants

lo

who haseitherbeencontinuously condition individualwith a disabling homeless person. An unaccompanied 6b. Chronicallyhomeless in ofhomelessness the past three(3) years. To be considered for homeless a year or more OR has had at leastfour (4) episodes housing)during shelter(i.e. not fransitional or chronicailyhomelessa personmust have beenon the streets in an emergency underthe CeneralInstructions see of furthei discussion the definitionof chronichomelessness, OtherKey Definitions thesestays. For above. individuals? were chronically homeless How nranyparticipants

,|,
a. tl.

Ethnicity. How many participantsare in the following ethnic categories? Hispanic Latino or No n-Hispa nic Non- Lat ino or o

22

Explanatory Notes: Eachparticipantshould be listed in only one cateeory. The total numberofparticipants in this table shouldequalthe number ofparticipants in question2b, columns 1 and 2.

8.
a. b. c. d.

Race. How many participantsare in the following racial categories? American Indian/Alaskan Native Asian Black/Afiican American Native Hawaiian/OtherPacihc Islander White f.
g

2 18 2

AmericanIndian/AlaskanNative & White

Asian White &

Black/African American & White AmericanIndian/AlaskanNative & Black/African American Other Multi-Racia]

h.
I

Notes: Explanatory I be a to not whos-q does correspond catesoriesthrouqh should A {ace be participant should listedin onlv onecategory. participant Each 2b, in of equal number participants question the in of ott'"i uutti Ru.iut. Thetotalnumber participants thistableshould *rnG categories. the to categories generate APR response response HMIS race you maycombine 1 *trn]* 'n:. Z If usingHMIS data, ^"d
9a, SpecialNeeds. How many participantshave the following? Participants mav have more than one. If so, count them in ALL applicablecategories.For eachcondition, also indicatethe number that were chronically homeless.

All
a.

Chronic Mentalillness

1
1n

b.
c d. f.
g

abuse Alcohol Drugabuse

diseases HIV/AiDS and reiated Developmentaldisability Physicaldisability Domesticviolence Other (pleasespecify)

10
tz

12
zo
z
A

za

2
t+

h.

are 9b. Horvmanyof theparticipants disabled? E Notes: Explanatory

10

HUD-40118

To determine r'vhich participants meetHUD's definitionof "disabled," "DisablingCondition"underother Key Definitions the General see in Instructions. 10' Prior Living Situation. Hor.vmany participantsslept in the following placesin the week prior to entering the project? (For each participant. choose one placp. The totalnumberof participants the "All" columnshouldequalthenumberof participantsin in quesion ?b, colut.nns and 2). Also, indicate I how many chronically homeless participants sleptin the foilowingplaces.(Choose one) AII Chronic Non-housing(street,park, car, bus station,etc.) Emergencyshelter Transitionalhousingfor homeless persons

b. c. d.
e

20
o
b

Psychiatric facility*
Substance abuse trealment lity* faci Hospital* Jail/prison* Domesticviolence situation Living with relatives/friends Rental housing Otber (pleasespecify)
z 1..
... i .

f
g

h.
t.

*ifa participant came from an institution (psychiatric facility,substance abuse treatment facility, hospital, orjail), butwasthere lessthan 30 daysandwasliving on thestreet in emergency or shelter before entering treatment the faciliiy,h.Ah. should counted eitherthe be in strect shelter or category. appropriate. as

Completequestions11 - 15 for ali participants who lpFT during the operating year (from 2c, columns I and 2).. The ter'r participantmeanssinglepersonsand adultsin families. It doesnot include childre*n or caieeivers. The term chronically homeIesspersonmeanSanunaccompaniedhomelessindividual*iil'@";;i'h;;;;""",i'"""''y homelessfor a year or nore oR has had at leastfour (4) episodes homelessnJss of in the past three(3) years.To be considered chronicallyhomelessa personmust havebeen on the sfreelsor in an emergency shelter(i.e. not transitionalhousing)dunng thesestays.

l1' Amount and sourceof Monthly Incomeat ENTRY and at EXIT. of those participants LEFT duringtheoperating who year,how manyparticipants at each were monthlyincome levelandwith each source incomei Also,please of place mont'rrly thE in"i*" r.,r.r andeach source income chronically of for homeless persons thesecond in column each of ciiart. rne number participants Chart of in A andB should thesame. be
AII All A. Monthiy Income at ENTRY No ncome Ctronic Chmnic C. Income Sources ENTRY At Supplemental SecurityIncome (SSI) b.
z tt

a.

1
z

b.
c.

$1 50

12

Social SecurityDisability Income (SSDI) SocialSecurity

d.

-s250 $25 - s500 $s0 - sr,000

blf

2
z
L

d.

General Public Assistance

TemporaryAid to Needy Families(TANF) program StateChildren'sHealth Insurance 1SCFilp; VeteransBenefits Emplolment Income UnemploymentBenefits VeteransHealth Care Medicaid Food Stamps

10
1
1

10
1

f.

$1001$15 0 0 $150r $20 0 0

t
o

c.
h

+ s2001

h.
I

k.
m.. n.

1 1 1

1 1 1

Other (please specify) No Financial Resources

ll

H U D - 4 Oi 8 1

AII All Income B, lvlonthly At EXIT No income

Chmnic C'luonic at D. IncomeSources EXIT a. SecurityIncome(SSI) Supplemental DisabilityIncome(SSDI) SocialSecurity Social Security
4a

12 2

b.

s1150
$151 525 0
z

b.
c.

d.
q

$25r - $500

1 11 1
1

1
11 1 1

d.

Assistance General Public

Aid to NeedyFamilies(TANF) Temporary (SCHIP) Program StateChildren'sHealthInsurance VeteransBenefits nentIncome EmPlolT UnemnlovmentBenefits

3
1

\)
1

s501s1.000
s l00l- $1 5 0 0

f
g

f.
g

st50r-s2000
+ 52001

h.

h.

J
t.
N.

VeteransHealth Care Medicaid Food Stamps

m.
ll.

specify) Other(please
No Financial Resources

Explanatory Notes: Table A: Monthllyincome at entry refersto the participant'smonthly income on the dav he/sheenteredthe proeram(i.e., on the program or entry date or as closeas possibleto that day). You shouldnot reporton income receivedbefore enteringthe progranr income received stay. during the program Table B: Monthiv income at exit refersto the participant'smonthly income on the day he/sheleft the program(i.e., on the program exit date or as closeas possibleto that day). You should not report on incomereceivedduring the programstay. ofincome on the day he/sheenteredthe proqram(i.e., on the program Table C: Jncome sourcesat entrv refersto the participant'ssources entry date or as closeas possibleto that day). You shouldnot report on sourcesof incomereceivedbeforeenteringthe programor income with no incomeat the time of program entry shouldbe reportedin categoryn, No Financial receivedduring the program stay. Participants Resources. of Table D: Jncome sourcesat exit refersto the participant'ssources income on the day he/sheleft the program(i.e., on the program exit date with no ofincome receivedduring the programstay. Participants or as closeas possibleto that day). You should not report on sources income at the time of program exit shouldbe reportedin categoryn, No Financial Resources.

who LEFT during the operatingyear (from 2c, columns 1 and 2), how many were in the project for the follor.ving 12a. Of thoseparticipants lengthsof time? Also, pleaseplace the iength of stay for chronically homelesspersonswho LEFT during the operatingyear in the column. second

a.

All Chronic Lessthan I month

b.
c d.
e

I to 2 months
3 - 6 months 7 months- 12 months l3 months- 24 months
a a

z
'7

f
h.

25m on rh s -3 v e a rs
4 ye ars- 5y ear s 6 ye ars- Tv ear s

8 years 10 vears Over 10 years

Notes: Explanatory

l2

FIUD.IOl I8

has only one Compute eachparticipant's length ofstay using the participant'sprogramentry dateand programexit date. Ifthe participant the program exit dateduring the operatingyear,calculatelength ofstay by subtracting programentry date from the programexit date. Ifthe prrtrcipanthas multiple progranrexit datesduring the operatinqvear.calculate lengthofstav for eachproqramstay(by subtractinsthe the proqramentrvdate from the proeramexit datefu Each participant should tle associatedwith only one length of stay category, The total numberof participantsin the first column("All") should in 2c, eqLral numberof participants question columns I and2. the 12b. Length of Stay in Program. For thoseparticipantswho did NOT LEAVE during the operatingyear (from 2d, columnsI and 2), how placethe lengthof stayfor chronicallyhomeless personswho did NOT LEAVE long havethey beenin the project?Also, please year in the second column. during the operating

Ail b. c. d. f.
v

Chronic Lessthan I month I to 2 months

3 - 6 months
7 months- l2 months 13 months - 24 months 25 mon t hs - 3y ear s 4vea rs- 5v ear s 6yea rs- Ty ear s 8 vears- 10 vears Over l0 years

8 16

8 16

12
8 11
4

12
11 4

h.
t.

ErplanatoryNotes: participant's program each ofstayusing participant's the entrydateandthelastdayofthe operating year.To calculate Compute length year.Eachparticipantshouldbe associated only length ofstay,subtract program enfrydatefrom the lastdayofthe operating the with ("All") should of in onelengthof staycategory.Thetotalnumber participants thefirstcolumn equal number participants question the of in 2d,columns and2. I participants LEFT theproject for who duringtheoperating (from2c, columns and2),howmany year 13. Reasons Leaving. Of those I left for thefollowingreasons? a participantleft for multiplereasons, If include onlvtheprimary reason,Thetotalnumber of participants the first column ("All") should in equalthenumber participants question columns and2. Also,please of in 2c, 1 place the primary reason chronicallyhomeless persons who !S during operating in thesecond for theproject the year column. program Left for a housing before completing opportunity
b. c. d. Completed program charge Non-paymentof rent/occupancy Non-compliancewith project Criminal activlty ldestruction of property'/ violence f.
o

All 4

Chronic 4 7

Reachedmaximum time allowed in proiect Needscould not be met by project with rules/persons Disagreement Death Other (pleasespecify) Unknown/disappeared

h.

J.
l,

t3

HUD-401l8

left rvho LEFT during the operatingyear (from 2c, columns I and 2), how man.v- for the follorving t-1. Destination. Of thoseparticipanrs se Ais de stin atio n? o, pleas eplac et hedes t inat iono f c h r o n i c a l l y h o m e l e s s p e r s o n s w h o ! p {! d u n n g t h e o p e r a t i n g y e a r i n th eco n d column. Ail PERMANENT (a-h) (no subsidy) Rentalhouseor apartment Chronic

b.
c.
A

Housi ng Public
8 Section ShelterPlus Care houseor aparfment HOME subsidized

2
R

2
I 1

fl
o

or house apartment Othersubsidized

Homeownership Moved in with family or fiiends persons Transitionalhousingfor homeless Moved in with family or friends hospital Psychiatric lnpatientalcohol or otherdrug treatmentfacility

h.

(i-1) TRANSITIONAL TNSTITUTION ft-m)

l.

J
tK.

m.

Jail/prison

(n) SHELTER EMERCENCY

OTHER (o-q)

shelter Emergency
housing Other supportive Placesnot meantfor human habitation(e.g. street) Other (please specify) Death Unknown
q

o.

p
q.

UNKNOWN

r.

Explanatory Notes: provided,The response categories combine upon leaving the programusing the categories Identify eachparticipant'sdestination transitional, etc.). etc.) and "tenure" (e.g.,permanent, public housing,homeownership, "destination" (e.g.,rental houseor apartment, response, and be sure to look at all ofthe response categories before Considerboth destinationand tenureto determinethe most appropriate category. making a selection. The table below provides a brief descriptionof eachresponse in Enter the number ofparticipants undereachdestinationcategory eitherthe first column ofthe table or in both columnsifthe participantis The total number of participantsin the first column Only one reasonfor leaving should be recordedper participant. chronically homeless. ("AIl") should equalthe number of participantsin question2c, columns 1 and2.

Tenure
Permanent

Destination
Rentalhouseor apartment(no subsidy) Publichousine 8 Section ShelterPlus Care houseor HOME subsidized aparlment house or apartment Other subsidized

Description

is withoutanysubsidy. to or Participant moving an apartment house

Particpant is moving to a public housing unit. will use a housingchoicevoucher(formerly known as a Participant Section8 voucher)to rent a houseor apartment. Participantis moving to a unit funded by the ShelterPlus Careprogram (e.e.,TBA, SRA, PRA, Section8 SRO). providedby the Participantis moving to a unit with rental assistance HOME Droqram(tenant-based proiect-based or assistance). Participantis moving to a unit subsidized someprogramother than by publichousing, program(formerlySection8), housing choicevoucher Shelter Plus Care.or HOME. is Panicipant movins to a unit thathe/shchaspurchased. Participantis moving in with family or friendsand expects live there to for 90 davs or more. Participantis moving into a unit funded by a transitionalhousing programfor homeless people(e.g.,transitionalhousingfunded through the SupportiveHousing Prosram). Partcipantis moving in r.vithfamily or friendsand expectsto live there lesshan 90 davs. Participantis movinq to a psvchiatrichospital. Participantis moving to an inpatientalcohol or druq fteatmentfacilitv.

b.

d.

h. Transitional
I

Homeownership Moved in with family or friends Transitionalhousing for homeless people

J
Instiiution
t.

Movedin with familyor friends

hospital Psychiatric Inpatientalcohol or other drug

t4

HUD-101 l8

Tenure m n.
o.

Destination treatment facility

Description

Jail/Prison
Emergency shelter Other supportivehousing

Participant moving a jail or prison. is to

Participant movingto an emergency is people sheiter honeless for Participantis moving into supportivehousingthat doesnot conespond to any ofthe permanent housingcategories (a-h)andis not transitional housing homeless gl for people(i), suchas Section I housine.*

Fma raa. ^, ,

S helte r Other

p.
q. Unknown

Placesnot meant for human habitation Other (pleasespecify)

Participant moving a place meant human abiiation. is to not for t such asa car,park,sidewalk, abandoned or building.
Participantis moving to a place that doesnoti*r.rpona categories above(a-p). to urryof tfr.

Unknown

Thisresponse category should usedifyffi be theparticipant movingor ifthe participant disappeared there is has and is no wayto find out where he/she is.

+HUD encottrages programs to limit the use of the "Other Supportive Housing" APR responsecotegory. prograrns sltould report destinatiottsto housing that are permatTentor transitional in APR categories (a) through (h) or in citegories 1iythrottgh e, iespectively Exils to emergencyshelters should be reported in category 1n1. 15' Supportive Services' Of thoseparticipantswho lEtr'I during the operatingyear (ffom 2, columns 1 and2),how many received the followrng supportiveservices during their time in the project? Also, please placeihe supportiveservicesreceivedfor chronically homelessparticipantswho LEFT during the operatingyear in the secondcolumn. Participants mav have received multiple services and ALL servicesshould be reported in the tatlle.

A ll

Chro nic a. Outreach

b.

16
IO

IO

Casemanagement Life skilis (outsideof casemanagement) Alcohol or drug abuseservices Mental health services HIV/AIDS-related services Other health care services Education Housingplacement Employrnentassistance Chiid care Transportation

16 16
A

c. d.

to

^
o to

f.
6.

'16 10
A A a

10
A a A

h
I

z
I

z
L

k
m. n.

to

16 8

Legal

Other specify) lplease

16. Overall Program Goals. Underobjectives, your measurable list objectivesfor this operatingyear (from your application, Technical 15 HUD_40118

and in describeyour progress meetingthe objectives, or Submission, AFR) tbr eachof the three goals listed below. Under Progress, year. Under Next operating Year's during this operating ob.lectives (with calculation)to.any measurable provide a progress ,Dercentage objectivesfor the next operatingyear' bb1..tiu.i, specifythe measurable a. ResidentialStabilitY

of for theirhousing a minimum will housing retain placedin permanent participants of program objectives:90% one yearafterplacement. placed permanent housing in (9 progress:90% Positive participant families out of '10) Matchprogram of all Match supportThe 52 Positive casemanagement of for retaintheirhousing a minimum one yearwithintensive period. Intensive case thiscontract housedduring remained San Francisco throughout housed famllies exitsfrom to modelof care designed ensurepermanent harm reduction provides integrated an management planning, for casemanagement permanency homebasedwraparound intensive include Services homelessness. weekly and rentalassistance, for directassistance food,clothing advocacy, treatment moneymanagement, case by livingwith or affected HIV/AIDS.The intensive and supportgroupsfor parentsand children activities and psychomentalhealth, legal, medical, housing, the program modelengages clientin maintaining management planning. and stability permanency in ireatment orderto improve social duringnextyear'scontract year,s with this objective To objectives: sustainthe successachieved Next operating period.
Increased Skills or Income

b.

within90 daysof entranceinto will benefits applyfor benefits 90% objectives: of familieswho are not receiving the program. .100% positiveMatchprogramparticipant or not benefits needing progress: families(10 out of '10) receiving of Matchfamilies The 52 Positive within90 days of programentrance. appliedfor benefits to changeiheir benefits the when entering program. or appliedfor benefits changedbenefits reviewedbenefits, duringnext year'soperating year's with this objeciive achieved To Next Operating Objectives: sustainprogress period.

c.

Greater Self-determination

as resources of will improvetheirsocialnetworkand utilization community 60% objectives: of families of by measured an analysis the clientrecord. in improvement theirsocial ('10 progress:.100% participants out of 10)demonstrated MatchProgram of positive Intensive case of by as resources measured analysis clientrecords. of networkand utilization community and use of community accessto socialnetworks with increased supportaffordsparticipants management and therapygroupsto Mothers positiveMatch provides supportive respitechildcare, weeklyperiodic resources. to: programs, including not limited but and activities educational and periodic art children, therapy, and violence, wellness' legalaid,domestic prevention positives, for
To objectives: sustain progress achieved with this objectiveduring next year's operating Nextoperatingyear's p e r iod.

d. ChildDevelopment

16

HUD-40118

and will activities improvesocialinteraction or in participating therapeutic respite 65%of chitdren Objectives: by progress measured an analysisof the clientrecord. as development or prooress: in 80o/" out of '10) 42 of the 52 positivematchfamilies participating therapeutic respite fB or of progress measured an analysis the client by as skillsand developmental socialinteraction improved activities '120 programs approximately children to tutoringand therapeutic We offersupportgroups,socialactivities, record. programincludes weekly.The activities limitprovidedto 30-40 children on ctients a weeklybasiswith a capacity playdates,familymovies, including daycare, activities groups, art, therapeutic children's tutoring, support weekly social, emotional, the support child's All therapy. of theseactivities and beachexcursions, individual rockclimbing, skilldevelopment. speechand interactive developmental,
I r vY,vvv,

collaborative specialized in To Year'sObjectives: increaseclientparticipation programmatic, Next Operating and achieve socialinteraction for aciivities childrenso that they will improve resources and therapeuticirespite progress. increased developmental

17. do

answer17c. (SHP'SSO projects 17b. SROrecipients answer l7a. S+Crecipients answer Beds. SHPrecipients rtot cornplete this questiott)
a. SHp. How many beds were includedin the applicationapproved for this project under 'Current Level' and under 'New Effort"/ How many of theseNew Effort beds were actually in place at the end of the operating year? Current Level in Place New Effort New Effort

ofBeds: Number

year? funds theendof theoperating at with unitswerebeingassisted project b. S+C. How manybedsanddwelling and other (Include beds all participants, familymembers, caregivers.) for of Number Beds: Number DwellingUnits: of year? at unitswerebeingassisted theendof theoperating SRO. How manydwelling persons qualifyfor assistance.) who non-homeless (Include by unitsoccupied "in place" of Number DwellingUnits:

20

t7

l8 HUD-401

Programs and Froun:Huusing Homeless

141EEEZF34

g1/23/2AEs 05:4r

P. f,853 0ml903

Pert II: Financial Information

18. Supportivc Scrviccsrhis crlibii prodcles iulbrr.rrrion rp HUD oa bow SHLfundinr fqr u}lmnivc sarvloef,Elalsql For Sqooorriyc:HoudpslSq, t1c opcrating y"rt- F-nr6 ilc rnounr of SHP funding s?ctrt ot lhcsc srpportivt scn'icrs' I-ucludc HMIS coss rodct 'Orltr". duritrg

S$ci.& thi-waluc of suaPo$i:vc s+'wicc.'i hord For Shcltcr PIus Cff (S+O, iLis erhitit ttck< tbe supportiv. sclviccs psrch rc4ulrcmtnt. rlrar atl. homclcss r.rsons ttccivcd durlgp thf nDartdng yerr. GtCgnmtccs shodd kcrrt sowcrs rhat can be counrcd uJ "ll -rarch s"*i.o'l artsl t'tp" of.tnr'*tt @ojtt".. ". "*otnl thc rrahnof sqlrooaivc scr'riseq teccived bv hoDclcss pasons during thc Fof Secflod SRe, rhis ochibir providcs information to HltD. on opcrauag ycr.

Supponive Scrriccs Outrdch b,

&sc n:anagomot

Dollers

sl64,025

Lifo stcillu(outridc of czscmanagcrnant) d. Alcohol and drrg:buse ssrviccs

Matalhealth scniccr

NDS-re!:,red scrviees O$erh*Irh que sravices

&lucbrion .Housing plrrcrtrnt E:rnployncnt assiscucc

e.
D,
l.

dL/

J.

Child csc

f,
$164.025

lnon/

t,
Il!

Tia:rsaonafioa Irgrl slcify) Indirect Costs O6a (plcase TOTAL (Sua of athmughn)

Ipvlofr l4Hffi$isJil-,lilrl,+n
v3EA12

{j'.i.,;i,Jri+rin?r,ib1#{ffitriit*lrtl'dfi n+#''=ii *tElffi&.iili#

Cuoulrtivc anroun!of m.ttchproirided to datc for thc S[dttr Flu.( Crrc h't4ren urrdcr this grat

IE

IILID-401l8

200' d

6 /,9 E Ig E 9 It

I^l ' 3' O ' S H tl

60:9I

8002- 82- NVf

COO'd TVJOI

Fron:Housing Homeless and Programs 1415558e84

01/2912808 [ts:41

fi853 P_ 0fB/003

Pro6ram: Leuing, Operating Costs" HMIS Acdvidcs and Administration 19. Supportive Supportive Scr9ccr, Eorrilg hora-"rn rnuglcemalatqlb All qr-rblee$-lcQqivjT,.L@qsjng cach ogcrJdn{ \/car. For etpasion proi"cts: IfSHPgrr*frndsarcforthccr,pansioaofaprc<cisriaghorclc<sfacrlity,onlydrcpcoplcandcxpcndiurrts'forthcadditi,onal cxparrsion nay bc includcd, as in the originel rpplication or any p:nr amcadrncnts. Docr:mcrrterinn nf rcsowccs li'cd ir not rcquirtd to bc inspectioo bv I{[ID-aruLA]4igE$. Do not indudc any uq,.rrdirures mrdc sr:bmined uirh rhirrcnonhEsloql,llglqpt on filejanossiblc bdorc chcSHP annr q/"s cxctutcd.

Summery of Erpedinrrts. Enrcr rhcarnountof SHPgranrffmds:rd ceshrnuch cxpcndcC during rhc opcrarir6 ycar for cachaciwity, This eblc shodd add up both horizonrrlly arrdvcrtielly- Thc SFIPsuppartiw scrviccstoutl shoulChc thc semcas rlc SHP si+psnivc
fcrnCcS Ur OrtcSUoo 18.

SIIP Frtads Leising

Cn.h Match

Toral Expcnditrrcs

$7,200
$164,025

$o
$436.412 $0

s7,200
$600,437
$U

Supponiw Scrrrices
Qpcrating Cosrs
d
c,

$o
cn

HMISActivifi,ce

Adminisrrfion
Totel

sB,s61
$179,786

s0 s0
9436,412
rDrytrorbcs}nsr xr andp.rrthg tirpcrlfc-

50 s8.551
$616,198

Norc:hSrrcrrs ofpritrcipelrrd intaer onmy lillr trrr*gl3c Sourtcs of Crsh Mrtch. shcer* asncccasary,

Enrcr rhc sorirccssf cssh idr*iEcd in 6a r-qh }4alch colunm,rbovq in tLc followiqg catcgorics-U,rc additioual

AIBoUDT a.
b-

G--anrccrbmicct spon5or clsb Local novrarnclt fplcesc spcci&) llwrraa Scrviccs A gcncy- Gcatrrl F\Ed Dcpt. oflubliE Hc.alth-Gcn*rl Flud SEtc covsrnogrr (olcssc sDecifu)

ftri:cll,.l:.t,..i irrii!lit{ffl fr

$r56_407 s66,e67 $,in::l

Fcda"al Eovcrncrcnt ioleasc specifv) Commnniw Developncnl Bleck Grgnt (CDEG)

j ;itiiiilhlilD,"+'F''::fr:;

UCSFfidc IV BII\IAEloswa
FounLrtioss (plcase spccifv)

$7I-r55
$141:883

I.

Privstc cash rcsourccs (please s?ecitv)

::::!-:e#.i,:ii+;{*

h.

Occupancv charc / fccs Tobl

$436.412

to

IIIJD.4OIIE

000' d

6 /,9 E L 9 9 EI?

N '3 'O 'S

H r-i

nT :

cT

Q n f l 7 _ o 7 -rrv n

20. Supportive Housing Program:

Acquisition, Rehabilitation, and Nelv Construction

must complete thesecharts the yearone APR in or All srantees received that rehabilitation. new construction SHP fundsfor acquisition. has enough cashto at leastequallynratchthe amountof SHP funds onlv. This exhibitwili demonstrate HUD that the grantee contributed to that Documentation matchinefundswere providedis not required bc submitted to spentfor acquisition, rehabilitation, new construction. or rr ,itn tnis re po rt Summary of Expenditures. Enterthe amountof SHP grant fundsand cashmatch expended during the operatingyear for eachactivity. SFIPFunds
a.

CashMatch

Total Expenditures

Acquisition Rehabilitation New construction Total

b
c.

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

Amount
Grantee/project sponsorcash b Local govemment(pleasespecify)

c.

(pleasespecify) Stategovernment

d.

(pleasespecify) Federalgovernment Community DevelopmentBlock Grant (CDBG)

(please Foundations specify)

(pleasespecify) Privatecashresources

Occupancy charge/fees Total

h.

20

HUD-1018 I

FOR HMIS ACTIWTIES OTVLY

2l . For Supportive Housins (SHP) - HMIS Activities e xh ibit ration to HUD fundin the amountof SHP-HMIS fundingspenron theseactivities. duri Enter

HMIS Activities Only Central Server(s) PersonalComputersand Printers Networking Security Subtotal Software/ User Licensing SoftwareInstallation Supportand Maintenance SupporlingSoftwareTools Subtotal

Dollars

Semices
Training by Third Parties Hostins/ TechnicalServices Programming: Customization

Programrning: System Interface Programming: Data Conversion SecurityAssessment and Setup On-line Connectivity (InternetAccess) Facilitation Disasterand Recovery

Subtotal
ProjectManagement/ Coordination Data Analysis Programming TechnicalAssistanceand Trainins Administrative Support Staff Subtotal

HMIS and SpaceCosts OperationalCosts

Total

21

HUD-40118

implementedduring Describeany problemsand/or changes

the operatingyear'

and Recommendations TechnicalAssistance I f s o , p l e a se d e scr i b e ' Based on yo ure xp e. enc edur ingt helas t y ear , ar et h e r e a n y a r e a s i n w h i c h y o u n e e d t e c h n i c a l a d v i c e o r a s s i s t a n c e ?

22

HUD-40118

PersonsServed Worksheet - HIID Annual Progress Report

Collectionof the ProtectedPersonalInformation (PPI) on this form is done with the knowledseor consent the clients. The of PPI is only used for the following pulpose: Accuratecompletionof the Annual ProgressReporl (APR) for the Continuumof Care(CoC) Homeiess Assistance Proqramrn which the clientis enrolled. Thisworksheet optional is intended helpyoucollect is and to information needed complete Annual to the Progress Report.Instructions and Codes follow. Do not submitthisworksheet HUD. to
Relationshrp Number of Months in Project(calcuiate) 12a Number of Months in Project Participant did not leave (calculate) l 2b Nerv Participant (Y /N )

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

4

Persons Served Worksheet (continued) Collection of the ProtectedPersonalInformation (PPI) on this form is done with the knowledge or consentof the clients. The PPI is only usedfor the following purpose: Accurate completion of the Annual ProgressReport (APR) for the Continuumof Care (CoC) Homeless program in Assistance which the client is enrol1ed.

Do not submit this rvorksheetto HUD

No Veterans Status(YN) 6a Chronically Homeless Ethnicity (code) 7 Race ( co d e ) 8 SpecialNeeds (code) 9a S pecral eeds N (code) 9b Prior Li vi ng S i tuati on (code) 10 Month)y lncome At
D-^;--+ E-+-,

(Y.a{)
6b

Montlrly Income At ProjectExit 1l b

I
(r I

l 1a

z)

HUD-40118

1A

HUD- 401r 8

Persons Served Worksheet (continued) (PPI)on thisform is donewith theknowledge consent theclients.The or of Information Personal of Collection theProtected PPIis onlyused thefollowingpurpose: for (APR)for theContinuum Care (CoC)Homeless Report of Assistance Program Accurate completion theAnnualProgress of in rvhich clientis enrolled. the
Do not submit this worksheetto HUD
Reasonfor Leaving
D"n- . - ' /a^i-\

I3

25

HUD-101l8

lnstructions and Codes for Persons Served Worksheet Th e use of t his wor k s heet is opt ional. I t w a s d e s i g n e d t o h e l p y o u c o l l e c t i n f o r m a t i o n o n pa rticip ant s needed t o c om plet e t he A n n u a l P r o g r e s s R e p o r t . I f t h e w o r k s h e e t i s u p d a t e d a s pa rticip ant s m ov e in and m ov e out of y o u r p r o j e c t , m o s t o f t h e i n f o r m a t i o n r e q u i r e d f o r c o m p l e t io n will b e c ont ained in t he wor k s heet . D o n o t s u b m i t t h i s w o r k s h e e t w i t h t h e A P R . Fo r pro jec t s t hat s er v e f am ilies , HUD o n l y r e q u i r e s r e p o r t i n g o n t h e n u m b e r o f c h i l d r e n s e r v e d , an d th e a ge and gender of t hes e c hildr e n . O n l y n a m e , r e l a t i o n s h i p , d a t e o f b i r t h , a n d a g e o n t h e rvorksh eet need t o be c om plet ed f or c h i l d r e n . A s s i g n t h e a d u l t s a n u m b e r , b u t n o t e a c h f a m i l y me mbe r. Us e t his num ber t o t r ans f er 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 . Be gin nin g wit h num ber 4, t he num ber s i n t h e c o l u m n s r e f e r t o t h e q u e s t i o n s o n t h e A P R f o r m . I f a ny q ue s iions ar e ans wer ed wit h "O t he r , " p l e a s e e n t e r t h 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 on in the APR. Participa nt Num ber . This c olum n' all o w s y o u to e ithe r num ber par t ic ipant s c ons ec u t i v e l y o r t o a ssign a c as e num ber . O ne num ber s h o u l d b e a ssign ed t o eac h adult . will not be r e p o r t e d t o Name . Nam es of per s ons HUD. Th e us e of nam es is f or y our r ec o r d k e e p i n g co nven ienc e. Re latio ns hip. Ent er t he appr opr iat e r e l a t i o n s h i p . Exa mple s inc lude: Self , Head of hous e h o l d , S p o u s e , ch itd. En try Da t e. Ent er dat e par t ic ipant en t e r e d t h e p roje ct. Us ually t his will be t he dat e o f a c t u a l p hysical m ov e- in f or a hous ing pr oject . Exit Da te. Ent er dat e par t ic ipant lef t t h e p r o j e c t . Usua lly t his will be t he dat e t he par t ic i p a n t p hysicall y m ov ed out f or a hous ing p r o j e c t . D o n o t in clu de a par t ic ipant r v ho t em por ar ily l e f t t h e p r o j e c t a nd is e x pec t ed t o r et ur n in les s t han 9 0 d a y s ( e . 9 . , h ospita liz at ion) . 4. In co m e- eligible Non- hom eles s in S R O . T h e S R O pro gr am allows as s is t anc e t o unit s o c c u p i e d b y Section 8 inc om e- eligible per s ons r e s i d i n g a t t h e S R O p r i o r t o r e h a b i l i t a t i o n . F o r S R O p r o j e cts on ly, indic at e whet her t he par t ic ip a n t i s a n i n c o m e - e l i g i b l e , n o n - h o m e l e s s p e r s o n ( Y ) o r n o t (N). SHP and S+ C pr ojec t s s hould s k i p t h i s i t e m .

5a . Da te of Bir t h. Ent er dat e of bir t h i n c l u d i n g m o n t h , d a y , a n d y e a r . 5b . Age . Ent er age at ent r y . 5c. Gen der . Ent er appr opr iat e let t er f o r g e n d e r . M-Ma le F- Fem ale. 5a . Ve ter ans St at us . I ndic at e if t he p a r t i c i p a n t i s a vele r an. Pleas e not e: A v et er an i s a n l t o n e w h o ha s e v er been on ac t iv e nt ilit ar y d t t t y s t a t u s f o r the U nit ed St at es . 6 b. Ch ron ic ally hom eles s per s on. I nd i c a t e t h e nu mber of par t ic ipant s t hat ar e c hr o n i c a l l y h ome les s . 7. Ethn ic it y . Ent er appr opr iat e let t e r f o r e t h n i c g r o u p . a . H i s pan ic or Lat ino

HUD-401 I8

b. No n- His panic or Non- Lat ino Race. Ent er appr opr iat e let t er f or r a c e . a. Am er ic an I ndian or Alas k an Nat i v e b . As ian c. Bl ac k or Af r ic an- Am er ic an d. Na t iv e Hawaiian or O t her Pac if i c I s l a n d e r e, Wh it e f . Am er ic an I ndian/ Alas k an Na t i v e & Wh i t e g. As ian & W hit e h . BI ac k / Af r ic an Am er ic an & Wh i t e i. Am er ic an I ndian/ Alas k an Nat iv e & Blac k / Af r ic an Am er i c an 1. Oth er M ult i- Rac ial 9 a. Spec ial Needs . Ent er t he let t e r ( s ) f o r t h e cate gor y ( ies ) t hat des c r ibe t he par t i c i p a n t 's d i s a b i l i t y ( i e s ) . ( Y o u m a y d o u b l e c o u n t ) . a . Ment al illnes s b. Alc ohol abus e c. Dru g abus e d. HIV/ AI DS and r elat ed dis eas es e. Dev elopm ent al dis abilit y f. Ph y s ic al dis abilit ies g. Do m es t ic v iolenc e h. Oth er ( pleas e s pec if y )

9b . Ente r t he num ber of par t ic ipant s w i t h a d i s a b i l i t y . 10 . Prior Liv ing Sit uat ion. Ent er t he l e t t e r t h a t b e s t d e s c r i b e s w h e r e t h e p a r t i c i p a n t s l e p t i n t h e we ek pr ior t o ent er ing t he pr ojec t , D o n o t d o u b l e c o u n t . a . No n-h ous ing ( s t r eet , par k , c ar , bus s t a t i o n , e t c . ) b . Emerg enc y s helt er c. Tran siti onal hous ing f or hom eles s pe r s o n s d . Psychia t r ic f ac ilit y * e . Su bstan c e abus e t r eat m ent f ac ilit y * f. Hospita l* g. Jail/p ris on* h. Do mest ic v iolenc e s it uat ion i. L ivin g wit h r elat iv es / f r iends j. Ren taI hous ing k. Oth er (pleas e s pec if y ) * lf a pa rtic ipant c am e f r om an ins t it ut io n b u t was th ere les s t han 30 day s and was liv i n g o n t h e stre et o r i n an em er genc y s helt er bef or e e n t e r i n g t h e facility, h e/ s he s hould be c ount ed in ei t h e r t h e s t r e e t or sh elte r c at egor y , as appr opr iat e.

I ns t r uc t io n C o d e s fo r P e rs o n sSe rv e d W or k s hee t (c o n ti n u e d ) I l a. G r oss Mo n th l y In c o me a t Pro j e c t E ntry. E n te r th e a mo u n to f g ro s s m o n t hl y i ncome the pr ojec t .

partrcipant is receiving at entry into the

I b. G r os s Mo n th l y In c o me a t Pro j e c t E xi t. E nter t he gr o s smo n th l y i n c o me th e p a rti ci panti s recei vi ng w hen exi ti ng the proj ect. lc . I nc om e S o u rc e sR e c e i v e da t Pro j e ct E ntry. E nt er a l l ty p e s o f a s s i s ta n c e e p a r ti ci panti s recei vi ng at entry to the proj ect. th a. S up p l e m e n taS e c u ri tyIn c o me (S S I) l b. S oc i a l S e c u ri tyD i s a b i l i ty In s u ra nce S D I) (S

27

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c. So c ial Sec ur t t Y d . Ge ner al Public As s is t anc e e . Tem por ar y Aid Needy Fam ilies ( T A N F ) f. State'Childt.n't Health InsuranceProgram(SCHIP) g . Vet er ans benef it s h. Em ploYm ent inc om e i. Un em PloYm ent benef it s j. Vet er ans Healt h Car e k. M edic aid L Food St am Ps m. Ot her ( Pleas e s Pec if Y) n . N o Financ ial Res our c es l ld .trncor ne Sour c es Rec eiv ed at Pr o j e c t E x i t ' receiving at project exit. (Use codes as in 11c.) En ter all t y pes of inc om e t he par ti c i p a n t i s 12 a L en gt h in St ay in Pr ogr am ' Cal c u l a . t e di t e m ' (See Ent r y Dat e and Ex it Dat e abo v e ') 1 2b . L en gt h of St ay in Pr ogr am ' ( Pa r t i c i p a n t d i d no t l- eav edur ing t he oper at in g y e a r' H o w l o n g ha v e t heY been in t he Pr ojec t ?) 1 3. Reas on f or Leav ing Pr ojec t ' E n t e r t h e p r i m a r y only for participants who left the rea s on why t he par t ic ipint lef t t h e p r o j e c t ' ( C o m p l e t e ex pec t ed t o r e t u r n w i t h i n 9 0 d a y s ' pro jec t uni ur . not a . ie f t f or a hous ing oppor t unit y b e f o r e com plet ing t he Pr ogr am b . C om Plet ed Pr ogr am c. N on- pay m ent of r ent / oc c upancy c h a r g e d. N on- c om Plianc e wit h Pr ojec t e . C r im inal ac t iv it y / des t r uc t ion o f p r o p e r t y / v i o l e n c e f. R eac hed m ax im um t im e allowe d i n p r o . l e c t g . Needs c ould not be m et bY Pr o j e c t h. D is agr eem ent wit h r ules / per s o n s i. D eat h j. Ot her ( Pleas e s Pec if Y) k. Unk nown/ dis aPPear ed Des t inat ion. Ent er t he des t i n a t i o n o f t h o s e lea v ing t he Pr ojec t . Per m anent : a. Rent al hous e or apar t m ent ( n o s u b s i d y ) b. Public Hous ing c . Sec t ion 8 d. Shelt er Plus Car e e. HO M E s ubs idiz ed hous e o r a p a r t m e n t f . O t her s ubs idiz ed hous e or a p a r t m e n t g. Hom eowner s hiP h. M ov ed in wit h f am ilY or f r i e n d s T ra ns it io n al I i. Tr ans it ional hous ing f or h o m e l e s s p e r s o n s j. M ov ed in wit h f am ilY or f r i e n d s trns t it ut ion: k . Ps Yc hiat r ic hos Pit al. 1. I npat ient alc ohoi or dr ug tr e a t m e n t f a c i l i t y m . J ail/ Pr is on Em er genc Y: n. Em er genc Y s helt er Oth e r : o. O t her s uPPor t iv e hous ing ' p. Plac es not m eant f or hum a n h a b i t a t r o n ( e. g. , s t r eet ) HUD-401i8

14 .

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q . O t her ( pleas e s pec if y ) Unknor v n: r . Unk nown 1 5. S uppor t iv e Ser v ic es . Ent er a l l t y p e s o f sup por t iv e s er v ic es t he par t ic ipant r e c e i v e d d u r i n g t h e t i m e i n t h e p r o j e c t . a . O ut r eac h b. Cas e m anagem ent c . Lif e s k ills ( out s ide of c as e m a n a g e m e n t ) d . Alc ohol or dr ug abus e s er v ic e s e . M ent al healt h s er v ic es f. HI V/ AI DS- r elat ed s er v ic es g. O r her healt h c ar e s er v ic es h. Educ at ion i. Hous ing plac em ent j. Em pioy m ent as s is t anc e k . Child c ar e
r. r I dlrSPUl t4t lut I

m. Legal n. Other (pleases

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