HUD-40110-D HOPWA Consolidated Annual Performance and Evaluation Rep

Housing Opportunities for Persons With AIDS (HOPWA) Program

Consolidated Annual Performance and

Evaluation Report (CAPER)

Measuring Performance Outcomes

OMB Number 2506-0133 (Expiration Date: XX/XX/XXXX)

The CAPER report for HOPWA formula grantees provides annual information on program accomplishments that supports program evaluation and the ability to measure program beneficiary outcomes as related to: maintain housing stability; prevent homelessness; and improve access to care and support. This information is also covered under the Consolidated Plan Management Process (CPMP) report and includes Narrative Responses and Performance Charts required under the Consolidated Planning regulations. Reporting is required for all HOPWA formula grantees. The public reporting burden for the collection of information is estimated to average 41 hours per manual response, or less if an automated data collection and retrieval system is in use, along with 60 hours for record keeping, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. HUD’s requirements for reports submitted by HOPWA formula grantees are supported by 42 U.S.C. § 12911 and HUD’s regulations at 24 CFR § 574.520(a). Grantees are required to report on the activities undertaken only, thus there may be components of these reporting requirements that may not be applicable. This agency may not 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. While confidentiality is not assured, HUD generally only releases this information as required or permitted by law.

Overview. The Consolidated Annual Performance and Evaluation Report (CAPER) provides annual performance reporting on client outputs and outcomes that enables an assessment of grantee performance in achieving the housing stability outcome measure. The CAPER fulfills statutory and regulatory program reporting requirements and provides the grantee and HUD with the necessary information to assess the overall program performance and accomplishments against planned goals and objectives.

HOPWA formula grantees are required to submit a CAPER demonstrating coordination with other Consolidated Plan resources. HUD uses the CAPER data to obtain essential information on grant activities, project sponsors,, housing sites, units and households, and beneficiaries (which includes racial and ethnic data on program participants). The Consolidated Plan Management Process tool (CPMP) provides an optional tool to integrate the reporting of HOPWA specific activities with other planning and reporting on Consolidated Plan activities.

Table of Contents

PART 1: Grantee Executive Summary

1. Grantee Information

2. Project Sponsor Information

5. Grantee Narrative and Performance Assessment

a. Grantee and Community Overview

b. Annual Performance under the Action Plan

c. Barriers or Trends Overview

PART 2: Sources of Leveraging and Program Income

1. Sources of Leveraging

2. Program Income and Resident Rent Payments

PART 3: Accomplishment Data: Planned Goals and Actual Outputs

PART 4: Summary of Performance Outcomes

1. Housing Stability: Permanent Housing and Related Facilities

2. Prevention of Homelessness: Short-Term Housing Payments

3. Access to Care and Support: Housing Subsidy Assistance with Supportive Services

PART 5: Worksheet - Determining Housing Stability Outcomes

PART 6: Annual Report of Continued Use for HOPWA Facility-Based Stewardship Units (Only)

PART 7: Summary Overview of Grant Activities

1. Information on Individuals, Beneficiaries and Households Receiving HOPWA Housing Subsidy Assistance (TBRA, STRMU, PHP, Facility Based Units, Master Leased Units ONLY)

2. Facility-Based Housing Assistance

Continued Use Periods. Grantees that used HOPWA funding for new construction, acquisition, or substantial rehabilitation of a building or structure are required to operate the building or structure for HOPWA-eligible beneficiaries for a ten (10) years period. If no further HOPWA funds are used to support the facility, in place of completing Section 7B of the CAPER, the grantee must submit an Annual Report of Continued Project Operation throughout the required use periods. This report is included in Part 6 in CAPER. The required use period is three (3) years if the rehabilitation is non-substantial.

Record Keeping. Names and other individual information must be kept confidential, as required by 24 CFR 574.440. However, HUD reserves the right to review the information used to complete this report for grants management oversight purposes, except for recording any names and other identifying information. In the case that HUD must review client-level data, no client names or identifying information will be retained or recorded. Information is reported in aggregate to HUD without personal identification. Do not submit client or personal information in data systems to HUD.

In connection with the development of the Department’s standards for Homeless Management Information Systems (HMIS), universal data elements are being collected for clients of HOPWA-funded homeless assistance projects. These project sponsor records would include: Name, Social Security Number, Date of Birth, Ethnicity and Race, Gender, Veteran Status, Disabling Conditions, Residence Prior to Program Entry, Zip Code of Last Permanent Address, Housing Status, Program Entry Date, Program Exit Date, Personal Identification Number, and Household Identification Number. These are intended to match the elements under HMIS. The HOPWA program-level data elements include: Income and Sources, Non-Cash Benefits, HIV/AIDS Status, Services Provided, Housing Status or Destination at the end of the operating year, Physical Disability, Developmental Disability, Chronic Health Condition, Mental Health, Substance Abuse, Domestic Violence, Medical Assistance, and T-cell Count. Other HOPWA projects sponsors may also benefit from collecting these data elements. HMIS local data systems must maintain client confidentiality by using a closed system in which medical information and HIV status are only shared with providers that have a direct involvement in the client’s case management, treatment and care, in line with the signed release of information from the client.

Operating Year. HOPWA formula grants are annually awarded for a three-year period of performance with three operating years. The information contained in this CAPER must represent a one-year period of HOPWA program operation that coincides with the grantee’s program year; this is the operating year. More than one HOPWA formula grant awarded to the same grantee may be used during an operating year and the CAPER must capture all formula grant funding used during the operating year. Project sponsor accomplishment information must also coincide with the operating year this CAPER covers.  Any change to the period of performance requires the approval of HUD by amendment, such as an extension for an additional operating year.

Final Assembly of Report. After the entire report is assembled, number each page sequentially.

Filing Requirements. Within 90 days of the completion of each program year, grantees must submit their completed CAPER to the CPD Director in the grantee’s State or Local HUD Field Office, and to the HOPWA Program Office: at HOPWA@hud.gov. Electronic submission to HOPWA Program office is preferred; however, if electronic submission is not possible, hard copies can be mailed to: Office of HIV/AIDS Housing, Room 7248, U.S. Department of Housing and Urban Development, 451 Seventh Street, SW, Washington, D.C., 20410.

Definitions

Adjustment for Duplication: Enables the calculation of unduplicated output totals by accounting for the total number of households or units that received more than one type of HOPWA assistance in a given service category such as HOPWA Subsidy Assistance or Supportive Services. For example, if a client household received both TBRA and STRMU during the operating year, report that household in the category of HOPWA Housing Subsidy Assistance in Part 3, Chart 1, Column [1b] in the following manner:

HOPWA Housing Subsidy Assistance		[1] Outputs: Number of Households
1.	Tenant-Based Rental Assistance	1
2a.	Permanent Housing Facilities: Received Operating Subsidies/Leased units	     
2b.	Transitional/Short-term Facilities: Received Operating Subsidies	     
3a.	Permanent Housing Facilities: Capital Development Projects placed in service during the operating year	     
3b.	Transitional/Short-term Facilities: Capital Development Projects placed in service during the operating year	     
4.	Short-term Rent, Mortgage, and Utility Assistance	1
5.	Adjustment for duplication (subtract)	1
6.	TOTAL Housing Subsidy Assistance (Sum of Rows 1-4 minus Row 5)	1

Administrative Costs: Costs for general management, oversight, coordination, evaluation, and reporting. By statute, grantee administrative costs are limited to 3% of total grant award, to be expended over the life of the grant. Project sponsor administrative costs are limited to 7% of the portion of the grant amount they receive.

Beneficiary(ies): All members of a household who received HOPWA assistance during the operating year including the one individual who qualified the household for HOPWA assistance as well as any other members of the household (with or without HIV) who benefitted from the assistance.

Chronically Homeless Person: An individual or family who : (i) is homeless and lives or resides individual or family who: (i) Is homeless and lives or resides in a place not meant for human habitation, a safe haven, or in an emergency shelter; (ii) has been homeless and living or residing in a place not meant for human habitation, a safe haven, or in an emergency shelter continuously for at least 1 year or on at least 4 separate occasions in the last 3 years; and (iii) has an adult head of household (or a minor head of household if no adult is present in the household) with a diagnosable substance use disorder, serious mental illness, developmental disability (as defined in section 102 of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (42 U.S.C. 15002)), post traumatic stress disorder, cognitive impairments resulting from a brain injury, or chronic physical illness or disability, including the co-occurrence of 2 or more of those conditions. Additionally, the statutory definition includes as chronically homeless a person who currently lives or resides in an institutional care facility, including a jail, substance abuse or mental health treatment facility, hospital or other similar facility, and has resided there for fewer than 90 days if such person met the other criteria for homeless prior to entering that facility. (See 42 U.S.C. 11360(2)) This does not include doubled-up or overcrowding situations.

Disabling Condition: Evidencing a diagnosable substance use disorder, serious mental illness, developmental disability, chronic physical illness, or disability, including the co-occurrence of two or more of these conditions. In addition, a disabling condition may limit an individual’s ability to work or perform one or more activities of daily living. An HIV/AIDS diagnosis is considered a disabling condition.

Facility-Based Housing Assistance: All eligible HOPWA Housing expenditures for or associated with supporting facilities including community residences, SRO dwellings, short-term facilities, project-based rental units, master leased units, and other housing facilities approved by HUD.

Faith-Based Organization: Religious organizations of three types: (1) congregations; (2) national networks, which include national denominations, their social service arms (for example, Catholic Charities, Lutheran Social Services), and networks of related organizations (such as YMCA and YWCA); and (3) freestanding religious organizations, which are incorporated separately from congregations and national networks.

Grassroots Organization: An organization headquartered in the local community where it provides services; has a social services budget of $300,000 or less annually, and six or fewer full-time equivalent employees. Local affiliates of national organizations are not considered “grassroots.”

HOPWA Eligible Individual: The one (1) low-income person with HIV/AIDS who qualifies a household for HOPWA assistance. This person may be considered “Head of Household.” When the CAPER asks for information on eligible individuals, report on this individual person only. Where there is more than one person with HIV/AIDS in the household, the additional PWH/A(s), would be considered a beneficiary(s).

HOPWA Housing Information Services: Services dedicated to helping persons living with HIV/AIDS and their families to identify, locate, and acquire housing. This may also include fair housing counseling for eligible persons who may encounter discrimination based on race, color, religion, sex, age, national origin, familial status, or handicap/disability.   

HOPWA Housing Subsidy Assistance Total: The unduplicated number of households receiving housing subsidies (TBRA, STRMU, Permanent Housing Placement services and Master Leasing) and/or residing in units of facilities dedicated to persons living with HIV/AIDS and their families and supported with HOPWA funds during the operating year.

Household: A single individual or a family composed of two or more persons for which household incomes are used to determine eligibility and for calculation of the resident rent payment. The term is used for collecting data on changes in income, changes in access to services, receipt of housing information services, and outcomes on achieving housing stability. Live-In Aides (see definition for Live-In Aide) and non-beneficiaries (e.g. a shared housing arrangement with a roommate) who resided in the unit are not reported on in the CAPER.

Housing Stability: The degree to which the HOPWA project assisted beneficiaries to remain in stable housing during the operating year. See Part 5: Determining Housing Stability Outcomes for definitions of stable and unstable housing situations.

In-kind Leveraged Resources: These are additional types of support provided to assist HOPWA beneficiaries such as volunteer services, materials, use of equipment and building space. The actual value of the support can be the contribution of professional services, based on customary rates for this specialized support, or actual costs contributed from other leveraged resources. In determining a rate for the contribution of volunteer time and services, use the criteria described in 2 CFR 200. The value of any donated material, equipment, building, or lease should be based on the fair market value at time of donation. Related documentation can be from recent bills of sales, advertised prices, appraisals, or other information for comparable property similarly situated.

Leveraged Funds: The amount of funds expended during the operating year from non-HOPWA federal, state, local, and private sources by grantees or sponsors in dedicating assistance to this client population. Leveraged funds or other assistance are used directly in or in support of HOPWA program delivery.

Live-In Aide: A person who resides with the HOPWA Eligible Individual and who meets the following criteria: (1) is essential to the care and well-being of the person; (2) is not obligated for the support of the person; and (3) would not be living in the unit except to provide the necessary supportive services. See t24 CFR 5.403 and the HOPWA Grantee Oversight Resource Guide for additional reference.

Master Leasing: Applies to a nonprofit or public agency that leases units of housing (scattered-sites or entire buildings) from a landlord, and subleases the units to homeless or low-income tenants. By assuming the tenancy burden, the agency facilitates housing of clients who may not be able to maintain a lease on their own due to poor credit, evictions, or lack of sufficient income.

Operating Costs: Applies to facility-based housing only, for facilities that are currently open. Operating costs can include day-to-day housing function and operation costs like utilities, maintenance, equipment, insurance, security, furnishings, supplies and salary for staff costs directly related to the housing project but not staff costs for delivering services.

Outcome: The degree to which the HOPWA assisted household has been enabled to establish or maintain a stable living environment in housing that is safe, decent, and sanitary, (per the regulations at 24 CFR 574.310(b)) and to reduce the risks of homelessness, and improve access to HIV treatment and other health care and support.

Output: The number of units of housing or households that receive HOPWA assistance during the operating year.

Permanent Housing Placement: A supportive housing service that helps establish the household in the housing unit, including but not limited to reasonable costs for security deposits not to exceed two months of rent costs.

Program Income: Gross income directly generated from the use of HOPWA funds, including repayments. See grant administration requirements on program income at 2 CFR 200.307.

Project-Based Rental Assistance (PBRA): A rental subsidy program that is tied to specific facilities or units owned or controlled by a project sponsor. Assistance is tied directly to the properties and is not portable or transferable.

Project Sponsor Organizations: Per HOPWA regulations at 24 CFR 574.3, any nonprofit organization or governmental housing agency that receives funds under a contract with the grantee to provide eligible housing and other support services or administrative services as defined in 24 CFR 574.300. Project Sponsor organizations are required to provide performance data on households served and funds expended.

SAM: All organizations applying for a Federal award must have a valid registration active at sam.gov. SAM (System for Award Management) registration includes maintaining current information and providing a valid DUNS number.

Short-Term Rent, Mortgage, and Utility (STRMU) Assistance: A time-limited, housing subsidy assistance designed to prevent homelessness and increase housing stability. Grantees may provide assistance for up to 21 weeks in any 52-week period. The amount of assistance varies per client depending on funds available, tenant need and program guidelines.

Stewardship Units: Units developed with HOPWA, where HOPWA funds were used for acquisition, new construction and rehabilitation that no longer receive operating subsidies from HOPWA. Report information for the units is subject to the three-year use agreement if rehabilitation is non-substantial and to the ten-year use agreement if rehabilitation is substantial.

Tenant-Based Rental Assistance (TBRA): TBRA is a rental subsidy program similar to the Housing Choice Voucher program that grantees can provide to help low-income households access affordable housing.  The TBRA voucher is not tied to a specific unit, so tenants may move to a different unit without losing their assistance, subject to individual program rules. The subsidy amount is determined in part based on household income and rental costs associated with the tenant’s lease.

Transgender: Transgender is defined as a person who identifies with, or presents as, a gender that is different from the person’s gender assigned at birth.

Veteran: A veteran is someone who has served on active duty in the Armed Forces of the United States.  This does not include inactive military reserves or the National Guard unless the person was called up to active duty.

Housing Opportunities for Person With AIDS (HOPWA)

Consolidated Annual Performance and Evaluation Report (CAPER)

Measuring Performance Outputs and Outcomes

OMB Number 2506-0133 (Expiration Date: 01/31/2021)

Part 1: Grantee Executive Summary

As applicable, complete the charts below to provide more detailed information about the agencies and organizations responsible for the administration and implementation of the HOPWA program. Chart 1 requests general Grantee Information and Chart 2 is to be completed for each organization selected or designated as a project sponsor, as defined by 24 CFR 574.3.

Note: If any information does not apply to your organization, please enter N/A. Do not leave any section blank.

1. Grantee Information

HUD Grant Number      			Operating Year for this report From (mm/dd/yy)       To (mm/dd/yy)      
Grantee Name      
Business Address	     
City, County, State, Zip	     		     			     	     
Employer Identification Number (EIN) or Tax Identification Number (TIN)	     
DUN & Bradstreet Number (DUNs):	     			System for Award Management (SAM):: Is the grantee’s SAM status currently active? ☐ Yes ☐ No If yes, provide SAM Number:
Congressional District of Grantee’s Business Address	     
*Congressional District of Primary Service Area(s)	                             
*City(ies) and County(ies) of Primary Service Area(s)	Cities:                              				Counties:                        
Organization’s Website Address      		Is there a waiting list(s) for HOPWA Housing Subsidy Assistance Services in the Grantee Service Area? ☐ Yes ☐ No If yes, explain in the narrative section what services maintain a waiting list and how this list is administered.

* Service delivery area information only needed for program activities being directly carried out by the grantee.

2. Project Sponsor Information

Please complete Chart 2 for each organization designated or selected to serve as a project sponsor, as defined by 24 CFR 574.3. Use this section to report on organizations involved in the direct delivery of services for client households.

Note: If any information does not apply to your organization, please enter N/A.

Project Sponsor Agency Name      		Parent Company Name, if applicable      
Name and Title of Contact at Project Sponsor Agency	     
Email Address	     
Business Address	     
City, County, State, Zip,	     
Phone Number (with area code)	     			     			     	     
Employer Identification Number (EIN) or Tax Identification Number (TIN)	     				Fax Number (with area code)      
DUN & Bradstreet Number (DUNs):	     
Congressional District of Project Sponsor’s Business Address	     
Congressional District(s) of Primary Service Area(s)	     
City(ies) and County(ies) of Primary Service Area(s)	Cities:      					Counties:      
Total HOPWA contract amount for this Organization for the operating year	     
Organization’s Website Address      
Is the sponsor a nonprofit organization? ☐ Yes ☐ No Please check if yes and a faith-based organization. ☐ Please check if yes and a grassroots organization. ☐			Does your organization maintain a waiting list? ☐ Yes ☐ No If yes, explain in the narrative section how this list is administered.

5. Grantee Narrative and Performance Assessment

a. Grantee and Community Overview

Provide a one to three page narrative summarizing major achievements and highlights that were proposed and completed during the program year. Include a brief description of the grant organization, area of service, the name(s) of the program contact(s), and an overview of the range/type of housing activities provided. This overview may be used for public information, including posting on HUD’s website. Note: Text fields are expandable.

     

b. Annual Performance under the Action Plan

Provide a narrative addressing each of the following four items:

1. Outputs Reported. Describe significant accomplishments or challenges in achieving the number of housing units supported and the number households assisted with HOPWA funds during this operating year compared to plans for this assistance, as approved in the Consolidated Plan/Action Plan. Describe how HOPWA funds were distributed during your operating year among different categories of housing and geographic areas to address needs throughout the grant service area, consistent with approved plans.

     

2. Outcomes Assessed. Assess your program’s success in enabling HOPWA beneficiaries to establish and/or better maintain a stable living environment in housing that is safe, decent, and sanitary, and improve access to care. Compare current year results to baseline results for clients. Describe how program activities/projects contributed to meeting stated goals. If program did not achieve expected targets, please describe how your program plans to address challenges in program implementation and the steps currently being taken to achieve goals in next operating year. If your program exceeded program targets, please describe strategies the program utilized and how those contributed to program successes. 

     

3. Coordination. Report on program coordination with other mainstream housing and supportive services resources, including the use of committed leveraging from other public and private sources that helped to address needs for eligible persons identified in the Consolidated Plan/Strategic Plan.

     

4. Technical Assistance. Describe any program technical assistance needs and how they would benefit program beneficiaries.

     

c. Barriers and Trends Overview

Provide a narrative addressing items 1 through 3. Explain how barriers and trends affected your program’s ability to achieve the objectives and outcomes discussed in the previous section.

1. Describe any barriers (including regulatory and non-regulatory) encountered in the administration or implementation of the HOPWA program, how they affected your program’s ability to achieve the objectives and outcomes discussed, and, actions taken in response to barriers, and recommendations for program improvement. Provide an explanation for each barrier selected.

☐ HOPWA/HUD Regulations ☐ Discrimination/Confidentiality ☐ Supportive Services ☐ Housing Affordability	☐ Planning ☐ Multiple Diagnoses ☐ Credit History	☐ Housing Availability ☐ Eligibility ☐ Rental History	☐ Rent Determination and Fair Market Rents ☐ Technical Assistance or Training ☐ Criminal Justice History
	☐ Geography/Rural Access ☐ Other, please explain further      

     

2. Describe any trends in the community that may affect the way in which the needs of persons living with HIV/AIDS are being addressed, and provide any other information important to the future provision of services to this population.

     

3. Identify any evaluations, studies, or other assessments of the HOPWA program that are available to the public.

     

End of PART 1

PART 2: Sources of Leveraging and Program Income

1. Sources of Leveraging

Report the source(s) of cash or in-kind leveraged federal, state, local or private resources identified in the Consolidated or Annual Plan and used in the delivery of the HOPWA program and the amount of leveraged dollars. In Column [1], identify the type of leveraging. Some common sources of leveraged funds have been provided as a reference point. You may add Rows as necessary to report all sources of leveraged funds. Include Resident Rent payments paid by clients directly to private landlords. Do NOT include rents paid directly to a HOPWA program as this will be reported in the next section. In Column [2] report the amount of leveraged funds expended during the operating year. Use Column [3] to provide some detail about the type of leveraged contribution (e.g., case management services or clothing donations). In Column [4], check the appropriate box to indicate whether the leveraged contribution was a housing subsidy assistance or another form of support.

Note: Be sure to report on the number of households supported with these leveraged funds in Part 3, Chart 1, Column d.

A. Source of Leveraging Chart

[1] Source of Leveraging	[2] Amount of Leveraged Funds	[3] Type of Contribution	[4] Housing Subsidy Assistance or Other Support
Public Funding
Ryan White-Housing Assistance			☐ Housing Subsidy Assistance ☐ Other Support
Ryan White-Other			☐ Housing Subsidy Assistance ☐ Other Support
Housing Choice Voucher Program			☐ Housing Subsidy Assistance ☐ Other Support
Low Income Housing Tax Credit			☐ Housing Subsidy Assistance ☐ Other Support
HOME			☐ Housing Subsidy Assistance ☐ Other Support
Continuum of Care			☐ Housing Subsidy Assistance ☐ Other Support
Emergency Solutions Grant			☐ Housing Subsidy Assistance ☐ Other Support
Other Public:			☐ Housing Subsidy Assistance ☐ Other Support
Other Public:			☐ Housing Subsidy Assistance ☐ Other Support
Other Public:			☐ Housing Subsidy Assistance ☐ Other Support
Other Public:			☐ Housing Subsidy Assistance ☐ Other Support
Other Public:			☐ Housing Subsidy Assistance ☐ Other Support
Private Funding
Grants			☐ Housing Subsidy Assistance ☐ Other Support
In-kind Resources			☐ Housing Subsidy Assistance ☐ Other Support
Other Private:			☐ Housing Subsidy Assistance ☐ Other Support
Other Private:			☐ Housing Subsidy Assistance ☐ Other Support
Other Funding
Grantee/Project Sponsor (Agency) Cash			☐ Housing Subsidy Assistance ☐ Other Support
Resident Rent Payments by Client to Private Landlord
TOTAL (Sum of all Rows)

2. Program Income and Resident Rent Payments

In Section 2, Chart A, report the total amount of program income and resident rent payments directly generated from the use of HOPWA funds, including repayments. Include resident rent payments collected or paid directly to the HOPWA program. Do NOT include payments made directly from a client household to a private landlord.

Note: Please see report directions section for definition of program income. (Additional information on program income is available in the HOPWA Grantee Oversight Resource Guide).

A. Total Amount Program Income and Resident Rent Payment Collected During the Operating Year

Program Income and Resident Rent Payments Collected		Total Amount of Program Income (for this operating year)
	Program income (e.g. repayments)	     
	Resident Rent Payments made directly to HOPWA Program	     
	Total Program Income and Resident Rent Payments (Sum of Rows 1 and 2)	     

B. Program Income and Resident Rent Payments Expended To Assist HOPWA Households

In Chart B, report on the total program income and resident rent payments (as reported above in Chart A) expended during the operating year. Use Row 1 to report Program Income and Resident Rent Payments expended on Housing Subsidy Assistance Programs (i.e., TBRA, STRMU, PHP, Master Leased Units, and Facility-Based Housing). Use Row 2 to report on the Program Income and Resident Rent Payment expended on Supportive Services and other non-direct Housing Costs.

Program Income and Resident Rent Payment Expended on HOPWA programs		Total Amount of Program Income Expended (for this operating year)
1.	Program Income and Resident Rent Payment Expended on Housing Subsidy Assistance costs	     
2.	Program Income and Resident Rent Payment Expended on Supportive Services and other non-direct housing costs	     
3.	Total Program Income Expended (Sum of Rows 1 and 2)	     

End of PART 2

PART 3: Accomplishment Data Planned Goal and Actual Outputs

In Chart 1, enter performance information (goals and actual outputs) for all activities undertaken during the operating year supported with HOPWA funds. Performance is measured by the number of households and units of housing that were supported with HOPWA or other federal, state, local, or private funds for the purposes of providing housing assistance and support to persons living with HIV/AIDS and their families.

1. HOPWA Performance Planned Goal and Actual Outputs

	HOPWA Performance Planned Goal and Actual		[1] Output: Households				[2] Output: Funding
			HOPWA Assistance		Leveraged Households		HOPWA Funds
			a.	b.	c.	d.	e.		f.
			Goal	Actual	Goal	Actual	HOPWA Budget		HOPWA Actual
	HOPWA Housing Subsidy Assistance		[1] Output: Households				[2] Output: Funding
1.	Tenant-Based Rental Assistance
2a.	Permanent Housing Facilities: Received Operating Subsidies/Leased units (Households Served)
2b.	Transitional/Short-term Facilities: Received Operating Subsidies/Leased units (Households Served) (Households Served)
3a.	Permanent Housing Facilities: Capital Development Projects placed in service during the operating year (Households Served)
3b.	Transitional/Short-term Facilities: Capital Development Projects placed in service during the operating year (Households Served)
4.	Short-Term Rent, Mortgage and Utility Assistance
5.	Permanent Housing Placement Services
6.	Adjustments for duplication (subtract)
7.	Total HOPWA Housing Subsidy Assistance (Columns a – d equal the sum of Rows 1-5 minus Row 6; Columns e and f equal the sum of Rows 1-5)
	Housing Development (Construction and Stewardship of facility based housing)		[1] Output: Housing Units				[2] Output: Funding
8.	Facility-based units; Capital Development Projects not yet opened (Housing Units)
9.	Stewardship Units subject to 3- or 10- year use agreements
10.	Total Housing Developed (Sum of Rows 8 & 9)
	Supportive Services		[1] Output: Households				[2] Output: Funding
11a.	Supportive Services provided by project sponsors that also delivered HOPWA housing subsidy assistance
11b.	Supportive Services provided by project sponsors that only provided supportive services.
12.	Adjustment for duplication (subtract)
13.	Total Supportive Services (Columns a – d equals the sum of Rows 11 a & b minus Row 12; Columns e and f equal the sum of Rows 11a & 11b)
	Housing Information Services		[1] Output: Households				[2] Output: Funding
14.	Housing Information Services
15.	Total Housing Information Services

	Grant Administration and Other Activities			[1] Output: Households				[2] Output: Funding
16.	Resource Identification to establish, coordinate and develop housing assistance resources
17.	Technical Assistance (if approved in grant agreement)
18.	Grantee Administration (maximum 3% of total HOPWA grant)
19.	Project Sponsor Administration (maximum 7% of portion of HOPWA grant awarded)
20.	Total Grant Administration and Other Activities (Sum of Rows 16 – 19)
	Total Expended							[2] Outputs: HOPWA Funds Expended
								Budget	Actual
21.	Total Expenditures for operating year (Sum of Rows 7, 10, 13, 15, and 20)

2. Listing of Supportive Services

Report on the households served and use of HOPWA funds for all supportive services. Do NOT report on supportive services leveraged with non-HOPWA funds.

Data check: Total unduplicated households and expenditures reported in Row 17 equal totals reported in Part 3, Chart 1, Row 13.

Supportive Services		[1] Output: Number of Households	[2] Output: Amount of HOPWA Funds Expended
1.	Adult day care and personal assistance	   	   
2.	Alcohol and drug abuse services	   	   
3.	Case management	   	   
4.	Child care and other child services	   	   
5.	Education	   	   
6.	Employment assistance and training	   	   
7.	Health/medical/intensive care services, if approved Note: Client records must conform with 24 CFR §574.310	   	   
8.	Legal services	   	   
9.	Life skills management (outside of case management)	   	   
10.	Meals/nutritional services	   	   
11.	Mental health services	   	   
12.	Outreach	   	   
13.	Transportation	   	   
14.	Other Activity (if approved in grant agreement). Specify:    	   	   
15.	Sub-Total Households receiving Supportive Services (Sum of Rows 1-14)
16.	Adjustment for Duplication (subtract)	   
17.	TOTAL Unduplicated Households receiving Supportive Services (Column [1] equals Row 15 minus Row 16; Column [2] equals sum of Rows 1-14)	   	   

3. Short-Term Rent, Mortgage and Utility Assistance (STRMU) Summary

In Row a, enter the total number of households served and the amount of HOPWA funds expended on Short-Term Rent, Mortgage and Utility (STRMU) Assistance. In Row b, enter the total number of STRMU-assisted households that received assistance with mortgage costs only (no utility costs) and the amount expended assisting these households. In Row c, enter the total number of STRMU-assisted households that received assistance with both mortgage and utility costs and the amount expended assisting these households. In Row d, enter the total number of STRMU-assisted households that received assistance with rental costs only (no utility costs) and the amount expended assisting these households. In Row e, enter the total number of STRMU-assisted households that received assistance with both rental and utility costs and the amount expended assisting these households. In Row f, enter the total number of STRMU-assisted households that received assistance with utility costs only (not including rent or mortgage costs) and the amount expended assisting these households. In row g, report the amount of STRMU funds expended to support direct program costs such as program operation staff.

Data Check: The total households reported as served with STRMU in Row a, column [1] and the total amount of HOPWA funds reported as expended in Row a, column [2] equals the household and expenditure total reported for STRMU in Part 3, Chart 1, Row 4, Columns b and f, respectively.

Data Check: The total number of households reported in Column [1], Rows b, c, d, e, and f equal the total number of STRMU households reported in Column [1], Row a. The total amount reported as expended in Column [2], Rows b, c, d, e, f, and g. equal the total amount of STRMU expenditures reported in Column [2], Row a.

Housing Subsidy Assistance Categories (STRMU)		[1] Output: Number of Households Served	[2] Output: Total HOPWA Funds Expended on STRMU during Operating Year
a.	Total Short-term mortgage, rent and/or utility (STRMU) assistance	   	   
b.	Of the total STRMU reported on Row a, total who received assistance with mortgage costs ONLY.	   	   
c.	Of the total STRMU reported on Row a, total who received assistance with mortgage and utility costs.	   	   
d.	Of the total STRMU reported on Row a, total who received assistance with rental costs ONLY.	   	   
e.	Of the total STRMU reported on Row a, total who received assistance with rental and utility costs.	   	   
f.	Of the total STRMU reported on Row a, total who received assistance with utility costs ONLY.	   	   
g.	Direct program delivery costs (e.g., program operations staff time)		   

End of PART 3

Part 4: Summary of Performance Outcomes

In Column [1], report the total number of eligible households that received HOPWA housing subsidy assistance, by type.

In Column [2], enter the number of households that continued to access each type of housing subsidy assistance into next operating year. In Column [3], report the housing status of all households that exited the program.

Data Check: The sum of Columns [2] (Number of Households Continuing) and [3] (Exited Households) equals the total reported in Column[1].

Note: Refer to the housing stability codes that appear in Part 5: Worksheet - Determining Housing Stability Outcomes.

Section 1. Housing Stability: Assessment of Client Outcomes on Maintaining Housing Stability (Permanent Housing and Related Facilities)

A. Permanent Housing Subsidy Assistance

	[1] Output: Total Number of Households Served	[2] Assessment: Number of Households that Continued Receiving HOPWA Housing Subsidy Assistance into the Next Operating Year	[3] Assessment: Number of Households that exited this HOPWA Program; their Housing Status after Exiting		[4] HOPWA Client Outcomes
Tenant-Based Rental Assistance	     	     	1 Emergency Shelter/Streets	     	Unstable Arrangements
			2 Temporary Housing	     	Temporarily Stable, with Reduced Risk of Homelessness
			3 Private Housing	     	Stable/Permanent Housing (PH)
			4 Other HOPWA	     
			5 Other Subsidy	     
			6 Institution	     
			7 Jail/Prison	     	Unstable Arrangements
			8 Disconnected/Unknown	     
			9 Death	     	Life Event
Permanent Supportive Housing Facilities/ Units	     	     	1 Emergency Shelter/Streets	     	Unstable Arrangements
			2 Temporary Housing	     	Temporarily Stable, with Reduced Risk of Homelessness
			3 Private Housing	     	Stable/Permanent Housing (PH)
			4 Other HOPWA	     
			5 Other Subsidy	     
			6 Institution	     
			7 Jail/Prison	     	Unstable Arrangements
			8 Disconnected/Unknown	     
			9 Death	     	Life Event

B. Transitional Housing Assistance

	[1] Output: Total Number of Households Served	[2] Assessment: Number of Households that Continued Receiving HOPWA Housing Subsidy Assistance into the Next Operating Year	[3] Assessment: Number of Households that exited this HOPWA Program; their Housing Status after Exiting		[4] HOPWA Client Outcomes
Transitional/ Short-Term Housing Facilities/ Units	     	     	1 Emergency Shelter/Streets	     	Unstable Arrangements
			2 Temporary Housing	     	Temporarily Stable with Reduced Risk of Homelessness
			3 Private Housing	     	Stable/Permanent Housing (PH)
			4 Other HOPWA	     
			5 Other Subsidy	     
			6 Institution	     
			7 Jail/Prison	     	Unstable Arrangements
			8 Disconnected/unknown	     
			9 Death	     	Life Event
B1: Total number of households receiving transitional/short-term housing assistance whose tenure exceeded 24 months			      

Section 2. Prevention of Homelessness: Assessment of Client Outcomes on Reduced Risks of Homelessness

(Short-Term Housing Subsidy Assistance)

Report the total number of households that received STRMU assistance in Column [1].

In Column [2], identify the outcomes of the households reported in Column [1] either at the time that they were known to have left the STRMU program or through the project sponsor’s best assessment for stability at the end of the operating year.

Information in Column [3] provides a description of housing outcomes; therefore, data is not required.

At the bottom of the chart:

• In Row 1a, report those households that received STRMU assistance during the operating year of this report, and the prior operating year.

• In Row 1b, report those households that received STRMU assistance during the operating year of this report, and the two prior operating years.

Data Check: The total households reported as served with STRMU in Column [1] equals the total reported in Part 3, Chart 1, Row 4, Column b.

Data Check: The sum of Column [2] should equal the number of households reported in Column [1].

Assessment of Households that Received STRMU Assistance

[1] Output: Total number of households	[2] Assessment of Housing Status		[3] HOPWA Client Outcomes
	Maintain Private Housing without subsidy (e.g. Assistance provided/completed and client is stable, not likely to seek additional support)	     	Stable/Permanent Housing (PH)
	Other Private Housing without subsidy (e.g. client switched housing units and is now stable, not likely to seek additional support)	     
	Other HOPWA Housing Subsidy Assistance	     
	Other Housing Subsidy (PH)	     
	Institution (e.g. residential and long-term care)	     
	Likely that additional STRMU is needed to maintain current housing arrangements	     	Temporarily Stable, with Reduced Risk of Homelessness
	Transitional Facilities/Short-term (e.g. temporary or transitional arrangement)	     
	Temporary/Non-Permanent Housing arrangement (e.g. gave up lease, and moved in with family or friends but expects to live there less than 90 days)	     
	Emergency Shelter/street	     	Unstable Arrangements
	Jail/Prison	     
	Disconnected	     
	Death	     	Life Event
1a. Total number of those households that received STRMU Assistance in the operating year of this report that also received STRMU assistance in the prior operating year (e.g. households that received STRMU assistance in two consecutive operating years).				     
1b. Total number of those households that received STRMU Assistance in the operating year of this report that also received STRMU assistance in the two prior operating years (e.g. households that received STRMU assistance in three consecutive operating years).				     

Section 3. HOPWA Outcomes on Access to Care and Support

1a. Total Number of Households

Line [1]: For project sponsors that provided HOPWA housing subsidy assistance during the operating year identify in the appropriate row the number of households that received HOPWA housing subsidy assistance (TBRA, STRMU, Facility-Based, PHP and Master Leasing) and HOPWA funded case management services. Use Row c to adjust for duplication among the service categories and Row d to provide an unduplicated household total.

Line [2]: For project sponsors that did NOT provide HOPWA housing subsidy assistance identify in the appropriate row the number of households that received HOPWA funded case management services.

Note: These numbers will help you to determine which clients to report Access to Care and Support Outcomes for and will be used by HUD as a basis for analyzing the percentage of households who demonstrated or maintained connections to care and support as identified in Chart 1b below.

Total Number of Households
For Project Sponsors that provided HOPWA Housing Subsidy Assistance: Identify the total number of households that received the following HOPWA-funded services:
Housing Subsidy Assistance (duplicated)-TBRA, STRMU, PHP, Facility-Based Housing, and Master Leasing
Case Management
Adjustment for duplication (subtraction)
Total Households Served by Project Sponsors with Housing Subsidy Assistance (Sum of Rows a and b minus Row c)
For Project Sponsors did NOT provide HOPWA Housing Subsidy Assistance: Identify the total number of households that received the following HOPWA-funded service:
HOPWA Case Management
Total Households Served by Project Sponsors without Housing Subsidy Assistance

1b. Status of Households Accessing Care and Support

Column [1]: Of the households identified as receiving services from project sponsors that provided HOPWA housing subsidy assistance as identified in Chart 1a, Row 1d above, report the number of households that demonstrated access or maintained connections to care and support within the operating year.

Column [2]: Of the households identified as receiving services from project sponsors that did NOT provide HOPWA housing subsidy assistance as reported in Chart 1a, Row 2b, report the number of households that demonstrated improved access or maintained connections to care and support within the operating year.

Note: For information on types and sources of income and medical insurance/assistance, refer to Charts below.

Categories of Services Accessed	[1] For project sponsors that provided HOPWA housing subsidy assistance, identify the households who demonstrated the following:	[2] For project sponsors that did NOT provide HOPWA housing subsidy assistance, identify the households who demonstrated the following:	Outcome Indicator
1. Has a housing plan for maintaining or establishing stable on-going housing	     	     	Support for Stable Housing
2. Had contact with case manager/benefits counselor consistent with the schedule specified in client’s individual service plan (may include leveraged services such as Ryan White Medical Case Management)	     	     	Access to Support
3. Had contact with a primary health care provider consistent with the schedule specified in client’s individual service plan	     	     	Access to Health Care
4. Accessed and maintained medical insurance/assistance	     	     	Access to Health Care
5. Successfully accessed or maintained qualification for sources of income	     	     	Sources of Income

Chart 1b, Line 4: Sources of Medical Insurance and Assistance include, but are not limited to the following (Reference only)

MEDICAID Health Insurance Program, or use local program name MEDICARE Health Insurance Program, or use local program name

Veterans Affairs Medical Services AIDS Drug Assistance Program (ADAP) State Children’s Health Insurance Program (SCHIP), or use local program name

Ryan White-funded Medical or Dental Assistance

Chart 1b, Row 5: Sources of Income include, but are not limited to the following (Reference only)

Earned Income Veteran’s Pension Unemployment Insurance Pension from Former Job Supplemental Security Income (SSI)

Child Support Social Security Disability Income (SSDI) Alimony or other Spousal Support Veteran’s Disability Payment Retirement Income from Social Security Worker’s Compensation

General Assistance (GA), or use local program name Private Disability Insurance Temporary Assistance for Needy Families (TANF) Other Income Sources

1c. Households that Obtained Employment

Column [1]: Of the households identified as receiving services from project sponsors that provided HOPWA housing subsidy assistance as identified in Chart 1a, Row 1d above, report on the number of households that include persons who obtained an income-producing job during the operating year that resulted from HOPWA-funded Job training, employment assistance, education or related case management/counseling services.

Column [2]: Of the households identified as receiving services from project sponsors that did NOT provide HOPWA housing subsidy assistance as reported in Chart 1a, Row 2b, report on the number of households that include persons who obtained an income-producing job during the operating year that resulted from HOPWA-funded Job training, employment assistance, education or case management/counseling services.

Note: This includes jobs created by this project sponsor or obtained outside this agency.

Note: Do not include jobs that resulted from leveraged job training, employment assistance, education or case management/counseling services.

Categories of Services Accessed	[1 For project sponsors that provided HOPWA housing subsidy assistance, identify the households who demonstrated the following:	[2] For project sponsors that did NOT provide HOPWA housing subsidy assistance, identify the households who demonstrated the following:
Total number of households that obtained an income-producing job	     	     

End of PART 4

PART 5: Worksheet - Determining Housing Stability Outcomes (optional)

1. This chart is designed to assess program results based on the information reported in Part 4 and to help Grantees determine overall program performance. Completion of this worksheet is optional.

Permanent Housing Subsidy Assistance	Stable Housing (# of households remaining in program plus 3+4+5+6)	Temporary Housing (2)		Unstable Arrangements (1+7+8)	Life Event (9)
Tenant-Based Rental Assistance (TBRA)	     	     		     	     
Permanent Facility-based Housing Assistance/Units	     	     		     	     
Transitional/Short-Term Facility-based Housing Assistance/Units	     	     		     	     
Total Permanent HOPWA Housing Subsidy Assistance	     	     		     	     
Reduced Risk of Homelessness: Short-Term Assistance	Stable/Permanent Housing	Temporarily Stable, with Reduced Risk of Homelessness		Unstable Arrangements	Life Events
Short-Term Rent, Mortgage, and Utility Assistance (STRMU)	     	     		     	     
Total HOPWA Housing Subsidy Assistance	     	     		     	     

Background on HOPWA Housing Stability Codes

Stable Permanent Housing/Ongoing Participation

3 = Private Housing in the private rental or home ownership market (without known subsidy, including permanent placement with families or other self-sufficient arrangements) with reasonable expectation that additional support is not needed.

4 = Other HOPWA-funded housing subsidy assistance (not STRMU), e.g. TBRA or Facility-Based Assistance.

5 = Other subsidized house or apartment (non-HOPWA sources, e.g., Section 8, HOME, public housing).

6 = Institutional setting with greater support and continued residence expected (e.g., residential or long-term care facility).

Temporary Housing

2 = Temporary housing - moved in with family/friends or other short-term arrangement, such as Ryan White subsidy, transitional housing for homeless, or temporary placement in institution (e.g., hospital, psychiatric hospital or other psychiatric facility, substance abuse treatment facility or detox center).

Unstable Arrangements

1 = Emergency shelter or no housing destination such as places not meant for habitation (e.g., a vehicle, an abandoned building, bus/train/subway station, or anywhere outside).

7 = Jail /prison.

8 = Disconnected or disappeared from project support, unknown destination or no assessments of housing needs were undertaken.

Life Event

9 = Death, i.e., remained in housing until death. This characteristic is not factored into the housing stability equation.

Tenant-based Rental Assistance: Stable Housing is the sum of the number of households that (i) remain in the housing and (ii) those that left the assistance as reported under: 3, 4, 5, and 6. Temporary Housing is the number of households that accessed assistance, and left their current housing for a non-permanent housing arrangement, as reported under item: 2. Unstable Situations is the sum of numbers reported under items: 1, 7, and 8.

Permanent Facility-Based Housing Assistance: Stable Housing is the sum of the number of households that (i) remain in the housing and (ii) those that left the assistance as shown as items: 3, 4, 5, and 6. Temporary Housing is the number of households that accessed assistance, and left their current housing for a non-permanent housing arrangement, as reported under item 2. Unstable Situations is the sum of numbers reported under items: 1, 7, and 8.

Transitional/Short-Term Facility-Based Housing Assistance: Stable Housing is the sum of the number of households that (i) continue in the residences (ii) those that left the assistance as shown as items: 3, 4, 5, and 6. Other Temporary Housing is the number of households that accessed assistance, and left their current housing for a non-permanent housing arrangement, as reported under item 2. Unstable Situations is the sum of numbers reported under items: 1, 7, and 8.

Tenure Assessment. A baseline of households in transitional/short-term facilities for assessment purposes, indicate the number of households whose tenure exceeded 24 months.

STRMU Assistance: Stable Housing is the sum of the number of households that accessed assistance for some portion of the permitted 21-week period and there is reasonable expectation that additional support is not needed in order to maintain permanent housing living situation (as this is a time-limited form of housing support) as reported under housing status: Maintain Private Housing with subsidy; Other Private with Subsidy; Other HOPWA support; Other Housing Subsidy; and Institution. Temporarily Stable, with Reduced Risk of Homelessness is the sum of the number of households that accessed assistance for some portion of the permitted 21-week period or left their current housing arrangement for a transitional facility or other temporary/non-permanent housing arrangement and there is reasonable expectation additional support will be needed to maintain housing arrangements in the next year, as reported under housing status: Likely to maintain current housing arrangements, with additional STRMU assistance; Transitional Facilities/Short-term; and Temporary/Non-Permanent Housing arrangements Unstable Situation is the sum of number of households reported under housing status: Emergency Shelter; Jail/Prison; and Disconnected.

End of PART 5

PART 6: Annual Report of Continued Usage for HOPWA Facility-Based Stewardship Units (ONLY)

The Annual Report of Continued Usage for HOPWA Facility-Based Stewardship Units is to be used in place of Part 7B of the CAPER if the facility was originally acquired, rehabilitated or constructed/developed in part with HOPWA funds but no HOPWA funds were expended during the operating year. Scattered site units may be grouped together on one page.

Grantees that used HOPWA funding for new construction, acquisition, or substantial rehabilitation are required to operate their facilities for HOPWA eligible individuals for at least ten (10) years. If non-substantial rehabilitation funds were used, they are required to operate for at least three (3) years. Stewardship begins once the facility is put into operation.

Note: See definition of Stewardship Units.

1. General information

HUD Grant Number(s)      	Operating Year for this report From (mm/dd/yy) To (mm/dd/yy) ☐ Final Yr ☐ Yr 1; ☐ Yr 2; ☐ Yr 3; ☐ Yr 4; ☐ Yr 5; ☐ Yr 6; ☐ Yr 7; ☐ Yr 8; ☐ Yr 9; ☐ Yr 10
Grantee Name      	Date Facility Began Operations (mm/dd/yy)      

2. Number of Units and Non-HOPWA Expenditures

Facility Name:      	Number of Stewardship Units Developed with HOPWA funds	Amount of Non-HOPWA Funds Expended in Support of the Stewardship Units during the Operating Year
Total Stewardship Units (subject to 3- or 10- year use periods)	     	     

3. Details of Project Site

Project Sites: Name of HOPWA-funded project	     
Site Information: Project Zip Code(s)	     
Site Information: Congressional District(s)	     
Is the address of the project site confidential?	☐ Yes, protect information; do not list ☐ Not confidential; information can be made available to the public
If the site is not confidential: Please provide the contact information, phone, email address/location, if business address is different from facility address	     

End of PART 6

Part 7: Summary Overview of Grant Activities

A. Information on Individuals, Beneficiaries, and Households Receiving HOPWA Housing Subsidy Assistance (TBRA, STRMU, Facility-Based Units, Permanent Housing Placement and Master Leased Units ONLY)

Note: Reporting for this section should include ONLY those individuals, beneficiaries, or households that received and/or resided in a household that received HOPWA Housing Subsidy Assistance as reported in Part 3, Chart 1, Row 7, Column b. (e.g., do not include households that received HOPWA supportive services ONLY).

Section 1. HOPWA-Eligible Individuals Who Received HOPWA Housing Subsidy Assistance

a. Total HOPWA Eligible Individuals Living with HIV/AIDS

In Chart a., provide the total number of eligible (and unduplicated) low-income individuals living with HIV/AIDS who qualified their household to receive HOPWA housing subsidy assistance during the operating year. This total should include only the individual who qualified the household for HOPWA assistance, NOT all HIV positive individuals in the household.

Individuals Served with Housing Subsidy Assistance	Total
Number of individuals with HIV/AIDS who qualified their household to receive HOPWA housing subsidy assistance.	 

Chart b. Prior Living Situation

In Chart b, report the prior living situations for all Eligible Individuals reported in Chart a. In Row 1, report the total number of individuals who continued to receive HOPWA housing subsidy assistance from the prior operating year into this operating year. In Rows 2 through 17, indicate the prior living arrangements for all new HOPWA housing subsidy assistance recipients during the operating year.

Data Check: The total number of eligible individuals served in Row 18 equals the total number of individuals served through housing subsidy assistance reported in Chart a above.

Category		Total HOPWA Eligible Individuals Receiving Housing Subsidy Assistance
1.	Continuing to receive HOPWA support from the prior operating year	 
New Individuals who received HOPWA Housing Subsidy Assistance support during Operating Year
2.	Place not meant for human habitation (such as a vehicle, abandoned building, bus/train/subway station/airport, or outside)	 
3.	Emergency shelter (including hotel, motel, or campground paid for with emergency shelter voucher)	 
4.	Transitional housing for homeless persons	 
5.	Total number of new Eligible Individuals who received HOPWA Housing Subsidy Assistance with a Prior Living Situation that meets HUD definition of homelessness (Sum of Rows 2 – 4)	 
6.	Permanent housing for formerly homeless persons (such as Shelter Plus Care, SHP, or SRO Mod Rehab)	 
7.	Psychiatric hospital or other psychiatric facility	 
8.	Substance abuse treatment facility or detox center	 
9.	Hospital (non-psychiatric facility)	 
10.	Foster care home or foster care group home	 
11.	Jail, prison or juvenile detention facility	 
12.	Rented room, apartment, or house	 
13.	House you own	 
14.	Staying or living in someone else’s (family and friends) room, apartment, or house	 
15.	Hotel or motel paid for without emergency shelter voucher	 
16.	Other	 
17.	Don’t Know or Refused	 
18.	TOTAL Number of HOPWA Eligible Individuals (sum of Rows 1 and 5-17)	 

c. Homeless Individual Summary

In Chart c, indicate the number of eligible individuals reported in Chart b, Row 5 as homeless who also are homeless Veterans and/or meet the definition for Chronically Homeless (See Definition section of CAPER). The totals in Chart c do not need to equal the total in Chart b, Row 5.

Category	Number of Homeless Veteran(s)	Number of Chronically Homeless
HOPWA eligible individuals served with HOPWA Housing Subsidy Assistance	 	 

Section 2. Beneficiaries

In Chart a, report the total number of HOPWA eligible individuals living with HIV/AIDS who received HOPWA housing subsidy assistance (as reported in Part 7A, Section 1, Chart a), and all associated members of their household who benefitted from receiving HOPWA housing subsidy assistance (resided with HOPWA eligible individuals).

Note: See definition of HOPWA Eligible Individual

Note: See definition of Transgender.

Note: See definition of Beneficiaries.

Data Check: The sum of each of the Charts b & c on the following two pages equals the total number of beneficiaries served with HOPWA housing subsidy assistance as determined in Chart a, Row 4 below.

a. Total Number of Beneficiaries Served with HOPWA Housing Subsidy Assistance

Individuals and Families Served with HOPWA Housing Subsidy Assistance	Total Number
1. Number of individuals with HIV/AIDS who qualified the household to receive HOPWA housing subsidy assistance (equals the number of HOPWA Eligible Individuals reported in Part 7A, Section 1, Chart a)	 
2. Number of ALL other persons diagnosed as HIV positive who reside with the HOPWA eligible individuals identified in Row 1 and who benefitted from the HOPWA housing subsidy assistance	 
3. Number of ALL other persons NOT diagnosed as HIV positive who reside with the HOPWA eligible individual identified in Row 1 and who benefited from the HOPWA housing subsidy	 
4. TOTAL number of ALL beneficiaries served with Housing Subsidy Assistance (Sum of Rows 1, 2, & 3)	 

b. Age and Gender

In Chart b, indicate the Age and Gender of all beneficiaries as reported in Chart a directly above. Report the Age and Gender of all HOPWA Eligible Individuals (those reported in Chart a, Row 1) using Rows 1-5 below and the Age and Gender of all other beneficiaries (those reported in Chart a, Rows 2 and 3) using Rows 6-10 below. The number of individuals reported in Row 11, Column E. equals the total number of beneficiaries reported in Part 7, Section 2, Chart a, Row 4.

HOPWA Eligible Individuals (Chart a, Row 1)
		A.	B.	C.	D.	E.
		Male	Female	Transgender M to F	Transgender F to M	TOTAL (Sum of Columns A-D)
1.	Under 18	 	 	 	 	 
2.	18 to 30 years	 	 	 	 	 
3.	31 to 50 years	 	 	 	 	 
4.	51 years and Older	 	 	 	 	 
5.	Subtotal (Sum of Rows 1-4)	 	 	 	 	 
All Other Beneficiaries (Chart a, Rows 2 and 3)
		A.	B.	C.	D.	E.
		Male	Female	Transgender M to F	Transgender F to M	TOTAL (Sum of Columns A-D)
6.	Under 18	 	 	 	 	 
7.	18 to 30 years	 	 	 	 	 
8.	31 to 50 years	 	 	 	 	 
9.	51 years and Older	 	 	 	 	 
10.	Subtotal (Sum of Rows 6-9)	 	 	 	 	 
Total Beneficiaries (Chart a, Row 4)
11.	TOTAL (Sum of Rows 5 & 10)	 	 	 	 	 

c. Race and Ethnicity*

In Chart c, indicate the Race and Ethnicity of all beneficiaries receiving HOPWA Housing Subsidy Assistance as reported in Section 2, Chart a, Row 4. Report the race of all HOPWA eligible individuals in Column [A]. Report the ethnicity of all HOPWA eligible individuals in column [B]. Report the race of all other individuals who benefitted from the HOPWA housing subsidy assistance in column [C]. Report the ethnicity of all other individuals who benefitted from the HOPWA housing subsidy assistance in column [D]. The summed total of columns [A] and [C] equals the total number of beneficiaries reported above in Section 2, Chart a, Row 4.

Category		HOPWA Eligible Individuals		All Other Beneficiaries
		[A] Race [all individuals reported in Section 2, Chart a, Row 1]	[B] Ethnicity [Also identified as Hispanic or Latino]	[C] Race [total of individuals reported in Section 2, Chart a, Rows 2 & 3]	[D] Ethnicity [Also identified as Hispanic or Latino]
1.	American Indian/Alaskan Native	 	 	 	 
2.	Asian	 	 	 	 
3.	Black/African American	 	 	 	 
4.	Native Hawaiian/Other Pacific Islander	 	 	 	 
5.	White	 	 	 	 
6.	American Indian/Alaskan Native & White	 	 	 	 
7.	Asian & White	 	 	 	 
8.	Black/African American & White	 	 	 	 
9.	American Indian/Alaskan Native & Black/African American	 	 	 	 
10.	Other Multi-Racial	 	 	 	 
11.	Column Totals (Sum of Rows 1-10)	 	 	 	 
Data Check: Sum of Row 11 Column A and Row 11 Column C equals the total number HOPWA Beneficiaries reported in Part 3A, Section 2, Chart a, Row 4.

*Reference (data requested consistent with Form HUD-27061 Race and Ethnic Data Reporting Form)

Section 3. Households

Household Area Median Income

Report the income(s) for all households served with HOPWA housing subsidy assistance.

Data Check: The total number of households served with HOPWA housing subsidy assistance should equal Part 3C, Row 7, Column b and Part 7A, Section 1, Chart a. (Total HOPWA Eligible Individuals Served with HOPWA Housing Subsidy Assistance).

Note: Refer to https://www.huduser.gov/portal/datasets/il.html for information on area median income in your community.

Percentage of Area Median Income		Households Served with HOPWA Housing Subsidy Assistance
1.	0-30% of area median income (extremely low)	 
2.	31-50% of area median income (very low)	 
3.	51-80% of area median income (low)	 
4.	Total (Sum of Rows 1-3)	 

Part 7: Summary Overview of Grant Activities

B. Facility-Based Housing Assistance

Complete one Part 7B for each facility developed or supported through HOPWA funds.

Do not complete this Section for programs originally developed with HOPWA funds but no longer supported with HOPWA funds. If a facility was developed with HOPWA funds (subject to ten years of operation for acquisition, new construction and substantial rehabilitation costs of stewardship units, or three years for non-substantial rehabilitation costs), but HOPWA funds are no longer used to support the facility, the project sponsor should complete Part 6: Continued Usage for HOPWA Facility-Based Stewardship Units (ONLY).

Complete Charts 2a, Project Site Information, and 2b, Type of HOPWA Capital Development Project Units, for all Development Projects, including facilities that were past development projects, but continued to receive HOPWA operating dollars this reporting year.

1. Project Sponsor Agency Name (Required)

     

2. Capital Development

2a. Project Site Information for HOPWA Capital Development of Projects (For Current or Past Capital Development Projects that receive HOPWA Operating Costs this reporting year)

Note: If units are scattered-sites, report on them as a group and under type of Facility write “Scattered Sites.”

Type of Development this operating year		HOPWA Funds Expended this operating year (if applicable)	Non-HOPWA funds Expended (if applicable)	Name of Facility:      
☐ New construction		$      	$     	Type of Facility [Check only one box.] ☐ Permanent housing ☐ Short-term Shelter or Transitional housing ☐ Supportive services only facility
☐ Rehabilitation		$     	$     
☐ Acquisition		$     	$     
☐ Operating		$     	$     
a.	Purchase/lease of property:			Date (mm/dd/yy):      
b.	Rehabilitation/Construction Dates:			Date started:       Date Completed:      
c.	Operation dates:			Date residents began to occupy:       ☐ Not yet occupied
d.	Date supportive services began:			Date started:       ☐ Not yet providing services
e.	Number of units in the facility:			HOPWA-funded units =       Total Units =      
f.	Is a waiting list maintained for the facility?			☐ Yes ☐ No If yes, number of participants on the list at the end of operating year      
g.	What is the address of the facility (if different from business address)?			     
h.	Is the address of the project site confidential?			☐ Yes, protect information; do not publish list ☐ No, can be made available to the public

2b. Number and Type of HOPWA Capital Development Project Units (For Current or Past Capital Development Projects that receive HOPWA Operating Costs this Reporting Year)

For units entered above in 2a, please list the number of HOPWA units that fulfill the following criteria:

	Number Designated for the Chronically Homeless	Number Designated to Assist the Homeless	Number Energy-Star Compliant	Number 504 Accessible – Mobility Units - Sensory Units
Rental units constructed (new) and/or acquired with or without rehab	   	   	   	   
Rental units rehabbed	   	   	   	   
Homeownership units constructed (if approved)	   	   	   	   

3. Units Assisted in Types of Housing Facility/Units Leased by Project Sponsor

Charts 3a, 3b, and 4 are required for each facility. In Charts 3a and 3b, indicate the type and number of housing units in the facility, including master leased units, project-based or other scattered site units leased by the organization, categorized by the number of bedrooms per unit.

Note: The number units may not equal the total number of households served.

Please complete separate charts for each housing facility assisted. Scattered site units may be grouped together.

3a. Check one only

Permanent Supportive Housing Facility/Units

Short-term Shelter or Transitional Supportive Housing Facility/Units

3b. Type of Facility

Complete the following Chart for all facilities leased, master leased, project-based, or operated with HOPWA funds during the reporting year.

Name of Project Sponsor/Agency Operating the Facility/Leased Units:    

Type of housing facility operated by the project sponsor		Total Number of Units in use during the Operating Year Categorized by the Number of Bedrooms per Units
		SRO/Studio/0 bdrm	1 bdrm	2 bdrm	3 bdrm	4 bdrm	5+bdrm
a.	Single room occupancy dwelling	   
b.	Community residence	   	   	   	   	   	   
c.	Project-based rental assistance units or leased units	   	   	   	   	   	   
d.	Other housing facility Specify:	   	   	   	   	   	   

4. Households and Housing Expenditures

Enter the total number of households served and the amount of HOPWA funds expended by the project sponsor on subsidies for housing involving the use of facilities, master leased units, project based or other scattered site units leased by the organization.

Housing Assistance Category: Facility Based Housing		Output: Number of Households	Output: Total HOPWA Funds Expended during Operating Year by Project Sponsor
a.	Leasing Costs	   	   
b.	Operating Costs	   	   
c.	Project-Based Rental Assistance (PBRA) or other leased units	   	   
d.	Other Activity (if approved in grant agreement) Specify:    	   	   
e.	Adjustment to eliminate duplication (subtract)	   
f.	TOTAL Facility-Based Housing Assistance (Sum Rows a through d minus Row e)	   	   

______________________________________________________________________________________

Previous editions are obsolete Page 1 form HUD-40110-D (Expiration Date: XX/XX/XXXX)