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(exp.11/30/2009) No.

OMB Approval 2506-0145

U. S. Department of Xlousing and Urban Development Ofhce of Community Planning and Develooment

Annual Progress Report (APR)


for SupportiveHousingProgram ShelterPlus Care and Section8 Moderate Rehabilitation for Single Room Occupancy Dwellings (SRO) Program

HUD-40118

including the time for reviewing instructions, Public reporting burden for this collectionof information is estimatedto average33 hours per response, Thi on . s earc h i n g e x i s t i n g d a t a s o u r ce s,g a th e r in g a n d m a in ta in in g thedataneeded,andcompl eti ngandrevi ew i ngthecol l ecti onofi nformati sag enc y may not conductor sponsor, and a personis not requiredto respondto, a collection of information unlessthat collection displaysa valid OMB control number.

General Instructions Purpose. The Annual Progress Report(APR) is a reporting tool that HUD usesto track program progressand accompiishments inform the Deparfment's and competitiveprocessfor homeless assistance funding. grants must submit 2 APR'S to HUD within 90 days after Filing Requirements. Recipients HUD's homelessassistance of the end of each operatins vear. One copy of the repofi must be submitted to the Community Planning and Development (CPD) Division Director in the local HtlD Field Offrce responsible for managingthe grant. The other copy must be submitted to HUD Headquarters, Deparlmentof Housing and Urban Development, Aftn: APR Data Editor, Room7262,45 1 7'n Sueet, SW, Washington, DC. 20410. Failure to submit an APR will delay receiving grant funds and may result in a determination of lack of capacity for future funding. An APR must be submitted for each operating year in which HUD funding is provided. Granteesthat received SHP funding for new construction, acquisition, or rehabilitation are required to operatetheir facilities for 20 years. They must submrt an APR 90 days after the end of the fust operating year and every year throughout the 20 years. A separatereport must be submitted for eachHUD grant received. For Shelter Plus Care (S+C), a separateAPR must be submitted for each S+C component. For thosegrantees receivingan extension, separate a report covering that period must be submitted(seeExtensionbelow). Recordkeeping. Granteesmust collect and maintain information on eachparticipant in order to complete an APR. Optional worksheetsare attached. The worksheetsmay be used to record information manually or to design a computerized systemto store and tabulate the information. The worksheetsshould not be submitted to HUD with the APR. Organization of the Report. The APR is organized in the following manner: Part I: Project Progress. This portion of the report describes progress moving homeless personsto self-sufficiency, in the documenting servicesreceived, listrng project goals, and accounting for beds/units. Part II: Financial Information. This porlion of the report is completed all grantees by receivingfunding under SHP, S+C, and SRO. tr'inal Assembly of Report. After the entire report is assembled,number every page sequentially. Mark any questionsthat do not apply to your program with "N/A" for not applicable. (See Special Insfructions for SSO Projects below.) Definitions of Clientltlousehold Types. Each client4rousehold type is definedbelow. Note that a client's clienVhousehold type should be basedon the client's age and/or household composition at the program entty date closest to the start ofthe operating year. Families - A family is a household at composed two or more relatedpersons, leastone of who is a child accompanied of by an adult or ajuvenile parent. Singles not in Families - Personsnot accompaniedby children, including pregnantwomen not accompaniedby other children and unaccompaniedyouth, are singles not in families. When two adults or fwo unaccompaniedyouth present togetherfor services, eachpersonshouldbe countedin singlesnot in families.. Clients' householdstatusshouldbe determinedbased on their householdcomposition at the program entry date closestto the start of the operating year. This meansthat pregnant women expectedto give birth during their program stay should still be counted as singles not in families. Adults in F amilies - Within a famrly, an adult is any person 18 yearsof age or older. For the purposesof APR reporting, the determinationof whether a person is an adult in family should be made basedon their age and household composition at the program entry date closestto the start ofthe operating year. by Children in Families - Childrenrn Familiesare dehnedas childrenunder the age of 18 accompanied one or more adults (parent, relative or guardian). Children ir famiLes also include both ajuvenile parent and the parent's child(ren). For the purposesof APR reporting, the determination of whether a person is a child in family should be made based on their age and household composition at the program entry date closestto the start of the operating year. For example,
HUD-401 18

clientswho are lessthan 18 yearsofage on the first day ofthe operatingyear or at program entry (ifthey enteredduring the operatingyear) should be counted as children even if they turn 18 during the course of the operating year, Personsin Families - Personsin famrliesincludesadultsin famrliesand children in famrlies.

terms are applieddifferently Other Key Delinitions. The following terms are used in the APR. As indicated,in somecases, whether the funding is from SHP, S+C, or SRO. depending on Chronically homelessperson - HUD dehnesa chronicallyhomeless personas "an unaccompanied rndividual homeless with a disabiingconditionwho has eitherbeen continuouslyhomeless a year or more OR hashad at leastfour (4) for episodes homelessness the past three(3) years." To be considered of in chronicallyhomeless, personmust have been on a the sheetsor in an emergencyshelter(i.e.,not in transitionalhousing)during thesestays. HUD's definition of a chronically homeless personis basedon the following components: . Unaccompanied homelessindividual: an unaccompanied homelessindividual hasthe samecharacteristics of a Singlenot in a Fanily (describedabove). o Disabling condition: seethe instmctionsunder disablingcondition (below) to determinewhethera client is disabled. Did not leave the program - This term refers to clients who were in the program on the last day of the operating year. Disabling condition - HUD definesa disablingcondition as: (l) A disability as definedin Section223 of the Social Security Act; (2) a physical, mental, or emotional impairment which is (a) expectedto be of long-continued and indefinite duration, (b) substantially impedes an individual's ability to live independently,and (c) of such a nature that such ability could be improvedby more suitablehousingconditions;(3) a developmental disability as defrnedin section102 of the Developmental DisabilitiesAssistance and Bill of RightsAct; (4) the disease acquiredimmunodeficiency of s1'ndrome or any conditions arising from the etiological agency for acquired immunodeficiency syndrome; or (5) a diagnosable substanceabusedisorder. Entered the program - Enteredthe programrefersto the first day a client receivesservices.For a residential program. this date would representthe fust day of residencein the program's housing. For services,this date may representthe day of program enrollment,the day a servicewas provided, or the first date of a period of continuous participationin a service (e.g.,daily, weekly, or monthly). For S+C and SRO programs, the program entry date is the date that the participant startsto receive rental assistance.For provided prior to this point are recognizedas necessary outreach/eruollment are eligible to count as S*C, services for and match. An Extension APR appliesto SHP and S+C grantees that requested and receivedan extensionof their grantterm from the HIJD field ofhce. The only difference between an APR for the extension period and the regular APR (besidesthe amountof time covered)is the signature page. Grantees shouldcircle "yes" to indicatethe APR is for an extension period and circle the operating year for which the report is an extension.For example, if the granteeis extending year 3, the granteeshould submit an APR as usual for year 3 and submit another APR for the extensionperiod, indicating the page. secondis an extensionand also circling year 3 on the signature Grantee meansa direct recipient of the HUD award. Left the program - Left the program refersto the last day a client receivesservices.For a residentialprogram,this date would represent last day of residence the program'shousing. For services, exit datemay represent last day the in the the a servicewas provided or the last dateofa period ofcontinuous service. Ifa client leavesthe programtemporarily(e.g., for a hospitalization) but is expectedto retum within 30 days, do not count that ciient as having left the program. For S+C programs, the program exit date refers to the date the participant stops receiving rental assistance and is not expectedto retuir to S+C assisted housing. If the participantrefumsto S+C assisted housingwithin 90 days,the person shouldnot be considered exiting from the program. If the personreturnsto S+C assisted as housingafter 90 days,that persorlis considered new participant. The worksheetis designed capturethis information. a to
HUD-40118

Match for S+C is the value of supportive servicesreceived by participants in the S+C project which, in the aggregate, provided over the life of the project. For SHP, match is cash must at least equal the value of the S+C rental assistance rehabilitation, new construction, operations and supportive services used to provide the grantee'sportion ofacquisition, expenses. activitiesfor acquisition, Operating year - For SHP progralns,the hrst operatingyearbeginsafter development rehabilitation, and new construction are complete, after a copy of the Cerlificate of Occupancy is sent to the local HUD office, and when the frrst participant is acceptedinto the project. For projects without acquisition, rehabilitationi or new construction,the operating start date begins when the granteeacceptsthe first participant. For dedicated HMIS projects, the operatingyearbeginswhen any eligible cost includedin the approvedproject budget is incurred. For S+C (SRA, PRA and TRA components),the first operating year begins on the date HUD signs the grant agreement. For S+C/SRO and for Sec. 8 SRO, the first operating year begins with the effective date of the Housing AssistancePa).rynents (HAP) Contract. To determine which operatingyear to circle on the APR cover page,begin counting from the initial grant operating start date and rnclude renewal grants. For example, a project receiving an initial grant for three years and a renewal grant for two years would circle years 1, 2, and3 respectively on the APR cover sheet for the initial grant and would circle 4 and 5 respectively for the renewal grant. For any future renewal grants,the granteewould begin by.circling 6 on the APR cover sheet. Participants - The term parlicipant refers to Singles not in Famrlies and Adults in Families as defined above. Participant does not include children or caregiverswho live with the adults assisted. Project Sponsor meansthe organization responsiblefor carrying out the daily operation of the project, if the organization is an entity other than the grantee.

Special Instructions for Supportive Service Only (SSO) Proqrams. SSO grantees should completeall questions, unless a written agreementhas been reachedwith the field office conceming which questionscan be answeredusing estimates, or in rare instances,skipped. Below is an exampleof how informationcould be derivedin a large,single-service SSOproject: A grantee/sponsor staff mernbercould be assignedto collect information from the organizationshousing the participants. The staff person would contact theseindividual organizationsto requestinformation regarding the personsin that facility that use the service. For participants living on the street, the granteeiprojectsponsormay provide estimates. Infomation could be collected for eachparticipant or for pafticipants receiving servicesat a point-in-time. If estimatesor point-in-time counts are used,the method used must be describedin the APR and the documentationkept on file. grants,grantees As with all projectsfundedunderHUD's homelessness operatingSSO projectsare expected to assistance complete all APR questionsthat are applicable to them. Note that all projects have been awarded funds as a result of responding to the program goals of assistinghomelesspersonsobtain/remainin permanenthousing and increasetheir skills and income. The APR documentstheir progress in meeting these goals. In some circumstancesfield offrces and granteesmay sign a written agreementconceming questionsthat can be answeredusing below for reporting on specialtypes of projects,suchas estimates, in rare instances, skipped. Seethe specialinstructions or outreachonly projects, projects providing servicesto children only, and transportation,medical, dental, and other single, shortdurationserviceprojects. SSO programs are a third priority for local HMIS implementation, following emergencyshelters,transitional housing programs, outreachprograrns,and permanentsupportive housing prograrns. Once SSO programs are inciuded in the HMIS, SSO grantees will be able to answer ali APR questionsusing their HMIS data. SSO granteesthat are not yet participating in HMIS wiii need to collect data to answer the APR questionsusing the special instructionsprovided above. are Outreach Only Projects. Projectswhich are solely devotedto streetoutreachand connectionto housingand services not required to track participants beyond their contact with personson the street. It is sufficient for theseproj ects to enter
HUD-401l8

questions 5-9 are allowed' given that 1-10 (skipping questions11-13 and 17). Estimatesfor on infor-rnation questrons questions' personal to may be reiuctant answer participants number of people, providing basic Answering the questionswill demonstratethat the granteeis serving the appropriate persons are being served' demonstratingthe tlpes of that homeless demographic information for Congress,demonstrat-ing they are receiving. to, housingparticipantsare connected and the type of services granteeand participantis often Hotline projects. Hotline servicesare similar to outreach only projects, but contactbetween prolects to answer of very short duration - people enter and leave the program nearly simultaneously. It is sufficient for these questions (skipping4), 10, and 14-19(skipping17). 1-5 projects providing Services Children only. Projects that provide child care, after school care, counseling for children' To While the main focus of the project is etc. make an important contribution toward moving a family out of homelessness. in questions6-16 of the APR. Like all other providing servicesto the children, it is the adults who are reported on prolects,lnis type is also targeted toward getting the families into housing and increasing the families' incomes. -Grunt""r may skip question 9; all other questionsshould be answered(except 17). provide a Transportation, Medical, Dental, and Other Single, Short=Duration Service Projects. Somegrantees on assistinghomelesspersonsto obtain/remain in permanent single slerviceof fairly short duration focused ONLY indirectly 1-10 and 14trouslng and increasetheir skills and incomes. It is sufficient for theseprojects to enter information on questions transportation sewices, it is unreasonableto think that someonewould have 19 (question l7 may be skipped). However, with to give their age, race, and ethnicity to a bus driver to get a ride a few blocks. provides estimates For these servlces,provide a narrative, which gives the number of rides given during the operating year, and service. on the above statisticsbased on the population that utilizes the For Safe Haven (SH) Proiects. Granteesshouldreporl on all participantsservedduring the Special Instructions from prior instructions where granteeswere instructed to report on the first 25 op.rxrrrg V.ur. Note: thir i. u "truttge parlicipants served.

Snecial

,t o"ta ntt out the cover sheetof the APR, Part II Financial Information, and the HMIS Activities section

s for

Man

nforma

MIS) Pro

HMIS grantees

HUD-40118

THIS PAGE . TO BE COMPLETED tsYALL GRANTEES


urantee:

Number: HUD Grantor Project

Agency HumanServices Cityand Countyof San Francisco,


ProjectSponsor:

007 OA39CB01
Project Name:

Episcopal munity eom Services


Operating Year: (Circle the operating year being reported on)

Ganon Barcus eommunity House


Reporting Period: (month,/day/year)

nr Dz tr: l+ Xs tro U ns !s nro


n rr Dr z [r : [r + nrs lto E tr nts lts lz o
Indicate ifextension: I Yes I ruo lndicate renewal: if El Y", E No
PreviousGrant Numbersfor this proiect:

from:4123106

to 4122/07

Checkthe componentfor the program on which you are reporting

Supportive Housing Program (S}IP) I I n ! ! TransitionalHousing Permanent Housing for Homeless Persons with Disabilities SafeHaven InnovativeSupportiveHousing SupportiveServicesOnly

Shelter Plus Care (S+C) I X X X Tenant-basedRental Assistance (TRA) (SRA) Rental Assistance Sponsor-based Project-basedRental Assistance (PRA) (SRO) R-oom Occupanc,v -Single

Section8 Moderate Rehabilitation fl Single RoomOccupancy (Sec. SRO) 8

fl HMrs
this operatingyear) with a descriptionof population, number servedand accomplishments Summary of the project: (One or two sentences CanonBarcusservicesl5 formerly homelessfamilies through the ShelterPlus Care Program,totally 54 individuals including children. use Many families are adverselyaffectedby one or more membershaving mental health and/or substance issues. Accomplishmentsinclude expansion servicesto vouth and mental health servicesfor families. of
Name & Title of the Person who can answer questions about this report:

(415) 487-3141 Phone:

Kevin Sharps, ECS Director of Housing


Address:

FaxNumber: &15) 487-3741

Episcopal CommunityServices 1658"'Street San Francisco, 94103 CA


E-mailAddress: ksharps @ecs-sf.org

I hereby certify that all the information stated herein is true and accurate.
false claims and statements.Conviction may result in criminal and/or civil Warning: HUD will prosecute 1010.10 12 : 3 l U.S.C.3729. 3802)
Name & Title of Authorized Grantee Official: Signature & Date:

(18U .S. C.

Analyst & Adviento, Stephen ShelterPlus Care Program Grants


Official NameandTitle of Authorized ProjectSponsor

v(rlor
/'/nz
HUD-401l8

Kevin Director Housing of Sharps,

PART I. TO BE COMPLETED BY ALL GRANTEES (EXCEPT

HMIS)

ON SEESPECIALINSTRACTIONS PAGE3 OF THEAPR PLEASE GRANTEES, SSO Part I: Project Progress


1.
lcat1on.

projected Level-of iersons to be-serveilat a given pointin time, (This information comesfrom the most recqnt CoC
Numberof Singles Not in Families
Number of Adults in Families

ProiectedLevel Persons be servedat a given point in time to

Number of Children in Families oo

Numberof Families tc

15

2.

PersonsServed during the operating year.


of Number Not Singles in Families Numberof Adultsin Families to
Number of Children in Families

Numberof Families

a.

Number on the first day of the operating year Number entering program during the operating year Number who left the program during the operating year

oo

15 0

b.

0 0 0

0
I

0 0
oo

0
IA

d.

Number in the program on the last day ofthe operating year (a+b -c):d

IC

Explanatory notes: SeeDefinitions of Client/HousehoidTlpes in the GeneralInskuctions aboveto determinewhich clients shouldbe countedas SinglesNot in Faprilies, Adults in Families, and Children in Families. Note that this table does not account for changesin clieni4rousehold type that may
,?^^- - - . r . . -:- -.L l ^ ^..--^ ^ r + L^ ^- ^- ^i:- u u L.u.l - u u r rrl B l l^ tr L u u l sE u f Lllu uPsr 4LulB yr d. r - ^' - va r r tsr- r t c^^L el i c nt c hnr r l r { hp ec c i m e.l a qi n- !c c l i entl hnr r c ehnl d tt- m e hac ed nn fhe eli g n t ' S

age and/or household composition at the progrant entry date closest to the start ofthe operatingyear. In this way, each client is counted only oncein the table. Use the following graphic and explanations to determinewho should be counted in rows a-d:

on Client program lirstdayof in year.lefrduring the operaling year couniin2a and2c. Clieni program llrstday on in qf openti ng earandl as l y year:count dayof operaling i n 2a and2d.
H Clieni enlered and leff Plogram during operating year count in 2b and 2c. Client entered program duilng operaijng year and slill in progfam gn last day ofyear count in 2b and 2d.

-i Clienl eniered and leff program before slarl of year do not counl In operatrnq queslon r.

i i I i

FiNt day oflhe opera!ng year

Last day ofthe operaong year

Number on the first day of the operating year: This row includesall clients who enteredthe programbeforethe first day of the operating year and did not leave the program until after the first day ofthe operating year. b. Number entering the program during the operating year: This row includesall clients who enteredthe programon or after the first day ofthe operating year, up to and including the last day ofthe operating year. For clients with multiple program entry dates,use the entry date closestto the start ofthe operatingyear.Do not count the ciient more than once evenifhe/she enteredthe programmore than once dudng the operating Year. Number who left during the operating year: This row includesall clientswho left the program on or after the hrst day of the operating year, up to and including the last day ofthe operating year. For clients with multiple program exit dates,use the exit date HUD-40118

closestto the end of the operatingyear.Do not count the client more than once even if he/sheexited the program more than onceduring
f hp nnor aiinn v por

d.

all Number in the program on the last day of the operatingyear: This row includes clientswho were in the programas ofthe first dqr;nfthe nneretinowearor who enteredduring the operatingyear and who did not leaveduring the operatingyear. The number of basedon the responses rows 2a through 2c. For to clients or families in the programon the last day ofthe operatrngyear is calculated eachcolurnn,add the number of clients or families in row 2a to the number of clients or families in row 2b and subtractthe number of clientsor familiesin row 2c. Therefore, = 2a + 2b - 2c. 2d

3.

Project Capacity.
Number of SinglesNot in Fami l i es Number of Adults in Fami l i es
l

Number of Children in Families

Number of Fami l i es

a.

Number on the last day (from 2d, columns I and 4) Number proposedin application(from 1a,columns 1 and 4) CapacityRate (divide aby b) - %

0
0 0%

15
tc

b. c.

100 %

Explanatory Notes: Rorv b refersto the most recentCoC applicationfor which the prograrnis reporting.

4.

Non-homeless persons.

This question is to be completed for Section 8 SRO projects. | N/A

personswere housedby the SRO programduring the operatingyear? Horv many incorne-eligible non-homeless

5.

Age and Gender. Of thosewho entered the project during the operatingyear, how many people are in the following age and gendercategories?
SinglePersons(from 2tr.column I b. c. d Ase 62 and over Maie Female

5l -61 31-50 18-30


17 and under

0 0 0 0 0 0 0
0

0
0 0

0 0
0

Personsin Families (from 2b. columns 2 & 3)

I
o

62 and over

h
J
1,

m.

51 - 61 3t - 50 l 8-30 13-17 6-12 1-5 UnderI

0
0

0
0

0 0 0 0 0 0 0

Explanatory Notes: who entered program year.Onlyclients not the duringtheoperating Thisquestion refers onlyto Singles in Families Persons Families and in in of reported underSinglePersons should equal the whomeetthese criteria be counted thistable.Thetotalnumber clients can be to reported under Persons Families in should equal thesumof number reported question column1. Thetotalnumber clients in 2b, of be to 2 2b. columns and3 in question Answer questions - 10 only for participants who entered the project during the operating year (from 2b, colunms1 & 2). 6 The term participant meansSinglesnot in Families and Adults in Families. It doesnot include children or caregivers.NOTE: The total for questions, 8 and 10 below shouldbe the same;respondto eachof thosequestionsfor al1participants. Someof 7, the questionslisted throughout the APR will be asking information for individuals who are ghrglgA|,.
HUD-401 I8

6a. Veterans Status. A veteranis anyonewho has ever been on active military duty status. How manyparticipants were veterans? I 0 I

6b. Chronically homelessperson. An unaccompanied homelessindividual with a disablingconditionwho has eitherbeen continuously homelessfor a year or more OR has had at leastfour (4) episodes ofhomelessness the past three(3) years. To be considered in chronicallyhomeless personmust have been on the streetsor in an emergency a shelter(i.e. not transitionalhousing)during thesestays. For further discussionof the definition of chronic homelessness, Other Key Definitions under the GeneralInstructions see above. How many participants were chronically homelessindividuals? I 0 |

7.
a.

Ethnicity. How many participantsare in the following ethnic categories? Hispanic or Latino Non-Hispanicor Non-Latino

b.

0 0

Explanatory Notes: Each participantshould be listed in only one category. The total number ofparticipants in this table should equal the number ofparticipants in question2b, columns 1 and 2.

8.
a.

Race. How many participantsare in the following racial categories? American Indian/Al askanNative Asran B lack/African Ameri can Native Hawaiian/OtherPacific Islander White American Indiar/Alaskan Native & White

b.
c.
.l

0 0
0

0
U

e f
q

h.

Asian& White BlacVAfricanAmerican& White


American Indiar/Alaskan Native & Black/African American

OtherMulti-Racial

0 0 0 0

Explanatory Notes: Each participantshould be listed in only one category. A participantwhoserace doesnot correspond categories through i should be to a countedin j, Other Multi Racial. The total number of participantsin this table should equal the number of participants question2b, in columns I and 2. If using HMIS data,you may combineHMIS race response categories generate APR response to the categories.

9a. Special Needs. How many participants have the following? Participants may have more than one. Ifso, count them in all applicablecategories.For eachcondition, also indicatethe number that were chronically homeless. AII Chronic Mental illness 0 0 b. Alcohol abuse 0 0 c. Drug abuse 0 0
d.

HIViAIDS and relateddiseases Develoomental disabilitv

f. g
h.

Physical disability
Domesticviolence Other (pleasespecify)

0 0 0 0
I

0 0

0 0 0

9b. Howmany theparticipants disabled? I 0 of are

HUD-40118

Explanatory Notes: meet HUD's definition of "disabled,"see"Disabling Condition" under Other Key Definitions in the General To determinl which participants Instructions. 10. Prior Living Situation. How many participantsslept in the following placesin the week prior to enteringthe project? (For each participant,chooseone place. The total number of participantsin the "Al1" column should equal the number of participantsin question2b, columns I and 2). Also, indicatehow many chronically homelessparticipantsslept in the following places. (Chooseone) All
a.

Chronic

b. c. d.
tr.

( , Non -ho us ings t r eetpar k ,c ar ,bus s t at ion, c . ) et Emergencyshelter persons Transitionalhousingfor homeless Psychiatric facility* facilitv+ Substance abusetreatment Hospital* Jailiprisonx Domesticviolencesituation Living with relatives/friends Rentalhousine Other (please specify)

0 0
0

0 0
0

0
0

f.
o

0 0
0

0 0 0 0.

h.
I

0
0

k.

*lfa participant (psychiatric came froman institution facility,substance abuse treatment facility,hospital, orjail), butwasthere lessthan 30 daysandwaslivingon thestreet in emergency or shelter entering treatment the facility,he/she before should counted either be in the street shelter or category. appropriate. as

Completequestions11 - 15 for all participants who left during the operating year (from 2c, columns 1 and 2). The terrn participant meanssingle personsand adults in families. It does not include children or caregivers. The term chronically homeless person meansan unaccompaniedhomelessindividual with a disabling condition who has either been continuously homeless a year or more OR hashad at leastfour (4) episodes homelessness the past three (3) years.To be considered for of in homelessa person must have been on the streetsor in an emergencyshelter (i.e. not transitional housing) during chronically these stays.

participants left duringtheoperating 11. Amount and Source Monthly Incomeat Entry and at Exit, Of those of who year, how many participants at each were place monthlyincome monthlyincome levelandwith each source income? Also,please of the levelandeach persons thesecond source ofincomefor chronically homeless in column ofeachchart. Thenumber ofparticipants Chart andB in A should thesame. be AI
A. Monthly Income at Entry No income Chronic C. Income SourcesAt Entrv
a.

AI

Chronic

a.

Supplemental SecurityIncome (SSI)

b
a

sr - 15 0
$15i - $2 5 0 $50 0 $251$501 $ 1 ,0 0 0 1

b.
c. d.

(SSDI) Social Security Disability Income


Social Security GeneralPublic Assistance TemporaryAid to Needy Families (TANF) 1

d.

0
f

f.

s1500 s1001s 1501- 2 0 0 0 S + $2001

State Children's HealthInsurance Program (SCHIP)


Veterans Benefits EmPlol'rnent Income UnemPlol,rnent Benefits

h.

h.

J
l.

VeteransHealth Care
Medi cai d

Food Stamps m.. n. Other (pleasespecify) No FinancialResources

t0

HUD-40118

AII B. Monthly Income at Exit No income b. c. d.

Chmnic D. Income Sources Exil at


a.
D.

Ail

Chronic

Supplemental SecurityIncome (SSf Social SecurityDisability Income (SSDI) Social Security

$ 1-150

s151 $250 $251$50 0 $501 $1 ,0 0 0 d

GeneralPublic Assistance Temporary Aid to NeedyFamilies (TANF;

0
f.
o

f.
0

s 1001- 5 0 0 $1

StateChildren's Health Insurance Program (SCHIP) VeteransBenefits Employnent Income Unemplol'rnent Benefits Veterans Health Care Medicaid Food Stamps Other (pleasespecify) No FinancialResources

$r501s2000
+ $2001

h.

h.
I

J
l,

I
m. n.

Explanatory Notes: Table A: Monthly income at entry refers to the participant's monthly income on the day he/sheenteredthe program (i.e., on the program entry date or as closeas possibleto that day). You should not report on income receivedbeforeenteringthe program or incomereceived during the programstay. Table B: Monthly income at exit refersto the participant'smonthly income on the day he/sheleft the program (i.e., on the programexit date or as close as possibleto that day). You should not report on income receivedduring the pro$am stay. Table C: Income sourcesat entry refersto the participant'ssourcesofincome on the day he/sheenteredthe program(i.e., on the program entry date or as closeas possibleto that day). You should not report on sources ofincome receivedbefore enteringthe program or income received during the program stay. Participants with no income at the time of progam entry should be reported in category n, No Financial Resources. Table D: Income sourcesat exit refersto the participant'ssourcesofincome on the day he/sheleft the program (i.e., on the programexit date or as close as possibleto that day). You should not report on sourcesofincome receivedduring the program stay. Participants with no income at the time of program exit shouldbe reportedin categoryn, No FinancialResources.

12a. Of thoseparticipantswho left during the operatingyear (from 2c, columns 1 and2), how many were in the project for the followrng lengthsof time? Also, pleaseplace the length of stay for chronically homelesspersonswho left during the operatingyear in the second column. All Chronic

b.
d. f. s. h.
l.

Lessthan 1 month 1 to 2 months


3 - 6 months

7 months 12months 13 months- 24 months 2 5mo nths - 3v ear s 4vea rs- 5v ear s

6v ear s -T v e a rs
8 years- l0 vears Over 10 years

ll

HUD-401 18

Explanatory Notes: Computeeachparticipant'slength ofstay using the participant'sprogram entry date and program exit date. Ifthe participanthas only one programexit date during the operatingyear,calculatelength ofstay by subtracting programentry date from the progam exit date. Ifthe the participanthas multiple program exit datesduring the operatingyear, calculatethe length ofstay for eachprogram stay (by subtractingthe programentry date from the program exit datefor eachprogramstay) and add them togetherto producea cumulativelength ofstay. Each participantshould be associated with only one length of stay category. The total number of participantsin the first column ("All") should equal the number ofparticipants in question2c, columns I and 2. 12b. Length of Stay in Program. For thoseparticipantswho did not leave during the operatingyear (from 2d, columns 1 and2), how long have they beenin the project? Also, pleaseplace the length ofstay for chronically homelesspersons who did not leave during the operatingyear in the secondcolumn. All
a,

Chronic

b.
c.

d. f
o

Lessthan 1 month I to 2 months 3 6 months 7 months - 12 months l3 months- 24 months 2 5mo nths - Sy ear s 4vea rs- 5v ear s

0 0
U

h.

6v ear s -T v e a rs
8 years- 10 years Over 10 years

Explanatory Notes: Computeeachparticipant'slength ofstay using the participant'sprogram enhy date and the last day ofthe operatingyear. To calculate length ofstay, subtractthe program entry date from the last day ofthe operatingyear. Each participantshould be associated with only one length ofstay category. The total number ofparticipants in the first colunm ("A11")shouldequal the number ofparticipants in question2d, columns I and 2.

13. Reasonsfor Leaving. Of thoseparticipants who lgft the project during the operatingyear (from 2c, columns 1 and 2), how many left for the following reasons?If a participantleft for multiple reasons, include onlv the primary reason. The total number of participants in the first column ("A11")should equal the number of participantsin question2c, columns 1 and2. Also, pleaseplace the primary reasonfor chronically homelesspersonswho left the project during the operatingyedr in the secondcolumn.

AII
a.

Chronic

Left for a housing opportunity before completing program Completedprogram Non-pay,rnentof rent/occupancycharge Non-compliance with project Criminal activity I destructionof property/ violence

b.
c. d.

f
g

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

h.
I

J
t.

t2

HUD-401 1B

14. Destination. Of thoseparticipantswho left during the operatingyear (from 2c, columns 1 and 2), how many left for the following destination?Also, pleaseplace the destinationof chronically homelesspersonswho !g[ during the operatingyear in the second column. All Chronic PERMANENT (a-h)
A

Rentalhouseor apartment(no subsidy) Public Housing Section8

b.

d.

SheiterPlus Care house or apartment HOME subsidized

f
CJ

house or apartmenl Other subsidized Homeownership Moved in with family or fiiends persons Transitionalhousing for homeless

h.

(i-j) TRANSTTTONAL
J

Moved in with familv or fiiends Psychiatric hospital Inpatient alcohol or other drug treatment facility Jail/prison Emergency shelter Other supportivehousing Placesnot meant for human habitation(e.g. street) Other (pleasespecify) Death

INSTITUTION(k-m)

1-

I
m. EMERGENCY SHELTER (n) n. o.

oTHER(o-q)

p.
q.

LiNKNOWN

Unknown

Explanatory Notes: provided. The response categories combine Identify eachparticipant'sdestinationupon leaving the programusing the categories transitional,etc.). public housing,homeownership, etc.) and "tenure" (e.g.,permanent, "destination"(e.g.,rental house or apartment, categories before and be sure to look at all ofthe response Considerboth destinationand tenureto determinethe most appropriateresponse, category. making a selection. The table below provides a briefdescriptionofeach response Enter the numberofparticipants under eachdestinationcategoryin either the first column ofthe table or in both columns ifthe participantis chronicallyhomeless. Only one reasonfor leaving shouldbe recordedper participant.The total number of participantsin the first column ("All") shouldequalthe number of participantsin question2c, columns 1 and 2

Tenure
Permanent
a.

b.

Destination Rental house or apartment(no subsidv) Public housine Section8

Description Participant is moving to an apartment or house without any subsidy P a r t i c i o a nits m o v i n s t o a p u b l i ch o u s i n gu n i t Participant will use a housing choice voucher (formerly known as a Section 8 voucher)to rent a houseor apartment. Participantis moving to a unit funded by the ShelterPlus Care prosram (e.e.,TBA, SRA, PRA, Section8 SRO).

d.

Shelter PlusCare ho o H O MEs u b s i d i z e d u s e r aDartmenr

Other subsidized house or apartment

provided the by is Participant movingto a unit with rentalassistance (tenant-basedproiect-based or assistance). HOME program otherthan by is Participant movingto a unit subsidized someprogram (formerly 8), program Section voucher publichousing, housing choice or PlusCare, HOME. Shelter
Particioantis movins to a unit that he/shehas purchased. Participant is moving in with family or friends and expects to live there for 90 davs or more. Participantis moving into a unit funded by a transitionalhousing programfor homelesspeople(e.g.,transitionalhousing funded through the SuooortiveHousine Proeram). Participantis moving in with family or friends and expectsto live there lessthan 90 davs. hospital. is Participant movinq to a psychiatric

g.

h. Transitional

Homeownership Moved in with family or fliends Transitionalhousing for homeless people

J
Institution
1.

Moved in with family or friends Psychiatrichospital

IJ

HUD-40118

Tenure

I
m

Emergency Shelter Other

n. o.

Destination Inpatient alcohol or other drug treatment facilitv Jail/Prison Emergencyshelter Other supportivehousing

Description

facility. to alcohol drugtreatment or Participant moving an inpatient is


Participantis movinq to a iail or prison. people. Participantis moving to an emergency shelterfor homeless Participantis moving into supportivehousingthat doesnot correspond (a-h) and is not transitional to any ofthe permanent housing categories people(i), suchas Section81t housine.* housingfor homeless Participantis moving to a place not meantfor humanhabitation,such as a car, park, sidewalk,or abandoned buildine. Participantis moving to a place that doesnot correspond any ofthe to categories above (a-o). This response categoryshould be used if you are unsureabout where the participantis moving or ifthe participanthas disappeared there and is no way to find out where he/she is.

p.
q. Unknown

Placesnot meantfor human habitation

Other(please specify)
Unknown

*HUD encouragesprograms to limit the use of the "Other Supportive Housing" APR responsecategory. Programs should report destinations to housing that are permanent or transitional in APR categories (a) through (h) or in categories (i) through (j), respectively. Exits to emergencyshelters should be reported in category (n).

15. Supportive Services. Of thoseparlicipantswho !g[ during the operatingyear (from 2, columns 1 and 2), how many receivedthe following supportiveservicesduring their time in the project? Also, pleaseplace the supportiveservices receivedfor chronically homelessparticipantswho left during the operatingyear in the secondcolumn. Participants may have receivedmultiple servicesand all servicesshould be reportedin the table. All Outreach b c.
A
4 I

Chronic

Casemanagement Life skills (outsideof casemanagement) Alcohol or drue abuse services Mental health services

0 0

f
g

HIV/AIDS-related services
Other health care services Education Housing placement

h.

J
t.

Employmentassistance Child care Transportation

m n.

Legal Other (pleasespecify)

T4

HUD-4018 I

l6'

gYerall Proeram Goats. Under objectives,list your measurable objectivesfor this operatingyear (from your application,Technical Submission, APR) for eachof the threegoals listed below. Under Progress, or describeyouiprogt.r. in meetingthe ob1ectives. Under Next OperatingYear's Objectives,specifythe measurable objectivesfor the next operatingy.ur. ResidentialStability

a.

objectives: 5o/o residentswill remain in housing for at least one year. 7 of Progress:Exceeded:Between 4123106 4122107, 100% 05115)of participanthouseholds that residedat CanonBarcusremainedhousedfor at leastone year. Next operating Year's objectives 75o/o residents remainin housingfor at leastone year. of will objective: 65% will remainin housing at leasttwo more years. for Progress:Achieved:BTV,(13/15) participants of remainedin housingfor at leasttwo years. Next Operating Year'sObjective:65% will remainin housing at leasttwo moreyears. for
b. Increased Skillsor Income

Objective: 80% of tenantswho are late in paying rent will participatein money management counselingor workshops, or formally enroll in a money management program. Progress:Achieved" 80% (415)of tenantswho were late in paying rent participatedin money management counselingor workshops,or formally enrolledin a money management program. Next Year's Objective: 80% of tenantswho are late in paying rent will participatein money management counselingor workshops, or formally enroll in a money managementprogram. objectives: 20o/o the tenants at any one time will be hired into part- or full-time employment of or will enter a vocational training program. Progress: 100% (15/15) of households had a memberwho was hired into part- or full-time employmentor entereda vocationalprogram. Next operating Year's objectives: 20o/o residents gain par! or full-time of will employment will entera vocational or training program.
c. Greater Self-determination

Objective: 600/o drugand alcoholaddictedtenantswill entertreatmenteachyear. of Progress:Not Measurable: Substance abusedisorderis not requirednor documented the Shelter for Plus Careunits, so no datais availablein this area, Next Year's Objective: 40Yoof drug and alcohol addictedparticipantswill entertreatmenteach

year.

Objective: 600/o tenants of who entertreatmentwill successfully completethe program. Progress: Status: We arenot awareof any residents who have attended substance treatment. use

15

HUD-40118

completethe program. of Next Year's Objective: 30Yo tenantswho entertreatmentwiil successfully will receiveongoinghealth careand remain in improved heaithand Objectives:95ohof tenants (including hygiene) eachyear, comparedwith their statusat program entry. improved appearance Progress:Not Achieved: 93oh(I4l15) of tenantsreceivedongoinghealthcareand remainedin (including hygiene) eachyear, comparedwith their statusat improved health and improved appearance program entry. who access Next Year's Objective: Within 90 daysof housing entry, 70Yoof households support plan, which establishes goals and objectivesand identifies services will develop an individualizedservice activitiesleadingto their accomplishments. children will attendschool. Objective: 100% of school-aged children attended school Progtess:Achieved:100%(3i3)of school-aged children will attendschool. of Next Year's Obiective: l00o/o school-aeed in programs organized children will participate after-school and school-aged Objective:80o% elementary of activities anyonetime. at participated after-school programs children in school-aged Progress: Achieved:I00% (313) elementary of activitiesat anyonetime. andorganized programs will participate after-school in school-aged children and 80o% elementary of Next Year'sObjective:
activities any one time. at organized and teenswill participatein recreationaland social activities and/orpreof Objective: 75o/o pre-teens programsat any one time. vocational of Progress:Achieved: I00% (1,2112) pre-teensand teensparticipatedin recreationaland social activities pre-vocational programs at any one time. andlor and teenswill participatein recreationaland social activities of Next Year's Objectrve: 75o/o pre-teens pre-vocational programs at any one time. andlor Objective: 50% of the tenantswill participatein tenantcouncil meetingsand/orpeer/socialactivitiesat least once a month. Progress:Achieved: 100% (15/15) of the tenantsparticipatedin tenantcouncil meetingsand/orpeer/social activitiesat least once a month. Next Year's Objective: 50% of the tenantswill participatein tenantcouncil meetingsandlorpeerisocial activitiesat least once a month.

17b. SROrecipients answer llc. (SHP-SSO projects do 17a. S+Crecipients answer answer 17. Beds. SHPrecipients not complete this question)
IO

HUD-40118

a.

SHP. How many bedswere includedin the applicationapprovedfor this project under 'Current Level' and under 'New Effort'? g How many of theseNew Effort bedsrvereactuallyin place at the end of the operatin year? New Effort New Effort in Place Current Level Nu mbe rolB eds : S+C. How many beds and dwelling units were being assisted with project funds at the end of the operatingyear? (Includebedsfor a1lparticipants, other family members, and caregivers.) Number of Beds: 39 Numberof Dwelline Units: 15

b.

c.

SRO. How many dwelling units were being assisted the end of the operatingyear? at (lnclude units occupiedby "in place" non-homeless persolrs who qualify for assistance.) Number of Dwelline Units:

Part II: Financial Information


18. Supportive Services. For SupportiveHousins (SHP), this exhibit providesinformationto HUD on how SHP funding for supportiveservices was spentduring the operating year. Enter the amount of SHP funding spenton thesesupportiveservices. Include HMIS costsunder "Other". For ShelterPlus Care (S+C), this exhibit tracksthe supportiveservices matchrequirement.Specifythe value ofsupportive servicesfrom all sources that can be countedas match that all homeless personsreceivedduring the operating year. (S+C grantees shouldkeep documentation file, including source,amount,and type ofsupportive services.) on For Section8 SRO, this exhibit provides informationto HLrD on the value of supportiveservices personsduring the receivedby homeless ear,

Supportive Services
a.

Dollars

Outreach Casemanagement (outsideof casemanagement) Life ski11s Alcohol and drug abuseservices Mental healthservices

b.
c. d.

7,1 1 $21 05.3

s100 s272.04
$ I ,670

I
a

AIDS-relatedservices Other healthcare services Education Housingplacement

h.

s3,772.38
$567.91

J
1.

Employmentassistance Child care Transportation

$2,000

m. n.

Legal

(please Other specify) Food, Furnishingsand

Food- $7,010.40 Furni shi ngs - 55.000 Toiletries/cleaning supplies $1,000 -

toiletries/cleaning supplies
o. TOTAL (Sum of a through n)

8,498.04 s23

Cumulative amount of match provided to date for the Shelter Plus Care Program under this srant

$1,519,313.04

L7

HUD-40118

19. Supportive Housing Program: Leasing, Supportive Services, Operating Costs, HMIS Activities and Administration All grantees recetvingfunding under the SupportiveHousing Programmust completethesechartseachoperatingyear.For expansion projects: IfSHPgra nt f unds ar ef or t heex pans ionof ap r e - e x i s t i n g h o m e l e s s f a c i l i t y , o n l y t h e p e o p l e a n d e x p e n d i t u r e s f o r th e a d d i ti o n a l expansion usedis not requiredto be may be included,as in the original applicationor any grant amendments.Documentationof resources submittedwith this report but should be kept on file for possibleinspectionby HUD and Auditors. Do not include any expenditures made beforethe SHP grantwas executed. - N/A Summary of Expenditures. Enter the amountof SHP grant funds and cashmatch expendedduring the operatingyear for eachactivity. This table shouldadd up both horizontally and vertically. The SHP supportiveservicestotal should be the sameas the SHP supportive services in ion 18 . - N/ A SHP Funds

TotalExpendrtures

SupportiveServices OperatingCosts HMIS Activities Administration

Note: Payments principal interest anyloanor mortgage notbe shown ar.r of and on may as operating expense. Sourcesof Cash Match. Enter the sourcesof cashidentified in the CashMatch column, above,in the following categories.Use additional sheets, necessary. N/A as Amount
a.

Grantee/project sponsorcash (pleasespecify) Local government

b.

c.

Stategovernment (pleasespecify)

d.

(pleasespecify) Federalgovernment

(CDBG) Community Development Block Grant

Foundations(pleasespecify)

f.

(pleasespecify) Private cashresources

g h.

Occupancycharge/ fees Total

18

HUD-40118

20. Supportive Housing Program: .A,cquisition, Rehabilitation, and New Construction


All grantees that receivedSHP funds for acquisition, rehabilitation, newconstruction complete or must these charts theyearoneAPR in only. This exhibit will demonstrate HUD thatthe grantee contributed to has enough cashto at leastequallymatchthe amount SHPfunds of spentfor acquisition, rehabilitation,or new construction. Documentation matching that funds wereprovided not required be submitted is to with this butshould kepton hle for possiblei be ion by HUD and Auditors. - N/A Summary of Expenditures. Enter the amount of SHP grant funds and cashmatch expended during the operatingyear for eachactivity SHP Funds
a.

CashMatch

Total Expenditures

Acquisition Rehabilitation New construction Total

b.
c d.

Cash Match. Enter the sources cashidentified in the CashMatch column, above,in the following categorres. of Use additionalsheets, necessary. as

Amount
Grantee/project sponsor cash b. Local govemment(pleasespecify)

c.

State government (pleasespecify)

d.

Federal government (pleasespecify) Community DevelopmentBlock Grant (CDBG)

Foundations (pleasespecify)

Privatecashresources (pleasespecify)

Occupancycharge/fees Total

h.

19

FIUD.4OI 8 I

FORHMIS ACTIWTIES OI,{LY


21. For SupportiveHousine (SHP) - HMIS Activities This exhibit providesinformation to HUD on how SHP-HMIS funding for supportiveserviceswas spentduring the operating year. Enter the amount of SHP-HMIS fundine sDenton theseactivities.- N/A

HMIS Activities Onlv

Dollars

E
CentralServer(s) PersonalComputersand Printers Networking

Securiry
Sabtotal

Sa
Software/ User Licensins SoftwareInstallation Supportand Maintenance SupportingSoftwareTools Subtotal

Services
Training by Third Parlies Hostins/ TechnicalServices Programming: Customization g: Programmin Svs{em Interface Programmine:Data Conversion SecuriryAssessment and Sefup On-line Connectivity (InternetAccess) Facilitation Disasterand Recovery Subtotal ProjectManagement Coordination / Data Analysis Programming TechnicalAssistance and Training Administrative Support Staff Subtotal

HMIS
SpaceCosts

anil,Operatiois

Operational Costs
Total

20

HUD-40118

Describe problems any and/or changes implemented during operating the year. The support ServicesManager,the lead servicesdevelopment staff on site, left employmentwith the project sponsor,Episcopal Community Services. Findingnew leadership the prolecthas been difficult for and protracted, but the remaining services staff is focusedand dedicated and doinga finejob i".int|..,e residents.

Technical Assistanceand Recommendations Based on your experienceduring the last year, are there any areasin which you need technical advice or assistance?Ifso, pleasedescribe.

ECS.woul-d certainly welcomereferrals qualifiedapplicants the SupportServicesManager of for role. ECS would also benefitfrom database consultant services ensuiethe highestefficiency data collection. to in Additionalmental health servicesthat utilize experienced therapists familieswould grealy enhanceservice for delivery and resident stability.

21

HUD-40118

PersonsServed Worksheet - HUD Annual Progress Report


Collection of the Protected PersonalInformation (PPI) on this fonn is done with the knowledgeor consentof the clients. The PPI is only usedfor the following pulpose: Accurate completion of the Annual ProgressReporl (APR) for the Continuum of Care (CoC) HomelessAssistanceProgram in which the client is enrolled. Thisworksheet optional is intended helpyou collectinformation is and to needed complete AnnualProgress to the Report. Instructions and Codes follow. Do not submitthis worksheet HUD. to
Number of Months in Project(calculate) l 2a Number of Months in Project -Participant did not leave (calculate) 12b

Non-Homeless (SI Only) ( Y/N ) 4

PersonsServed Worksheet (continued)


Collection of the ProtectedPersonal Information (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 Continuum of Care (CoC) HomelessAssistanceProsram in which the client is enrolied.

Do not submit this worksheet to HUD No Veterans Chronically Ethnicity


Status (Y,Ai) 6a Homeless (Y,At) 6b

Race (code) 8

SpecialNeeds (code) 9a

SpecialNeeds (code) 9b

Prior
T i . , i -v lilE, Lt

Monthly Income At

Monthly Income
rAt r! Pr^ia^r r rvJwv! E-;r L^rl

Ir (
I

Situation 10

Project Entry
11a

1lb

22

HUD-40118

HUD-1018 l

Persons Served Worksheet (continued) Collectionof theProtected Personal Information(PPI) on this form is donewith the knowledge consent the clients. The or of PPI is only usedfor the followingpurpose: Accurate completion theArurualProgress of prosramm Reporl(APR) for the Continuum Care(CoC)Homeless of Assistance whichthe clientis enrolled.
Do not submit this worksheet to HUD
Reasonfor Leaving Program (code) 13 SupportiveServices (code) 15

Instructions and Codes for PersonsServed Worksheet T he use o f th is wo rk s heet is opt ional. I t was des i g n e d t o he lp yo u co llect i nf or m at ion on par t ic ipant s ne e d e d t o comple te th e An nual Pr ogr es s Repor t . I f t he works he et is up da ted as par t ic ipant s m ov e in and m o v e out of you r pro ject, m os t of t he inf or m at ion r equi r e d f or comple tion will be c ont ained in t he wor k s heet . D o not s u bmit th is wo rk s heet wit h t he ApR. F or p roje cts th at se r v e f am ilies , HUD only r equir e s repor ting o n the nu m ber of c hildr en s er v ed, and t h e age a n d g en de r o f th es e c hildr en. O nly nam e, relationship , da te o f bir t h, and age on t he wor k s he e t
1A

n e e d t o b e c o m p l e t e d f o r c h i l d r e n . A s s i g n t he a d u l ts a n u m b e r , b u t n o t e a c h f a m i l y m e m b e r . U s e t hi s n u m b e r t o t r a n s f e r 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 et. B e g i n n i n g w i t h n u m b e r 4 , t h e n u m b e r s i n t h e co l u m n s refer to the questions on the APR form. If any q u e s t i o n s a r e a n s w e r e d w i t h " O t h e r , " p l e a s e e n te r th e specific "Other" answer for inclusion in the ApR. Participant Number. This column allows you t o e i t h e r n u m b e r p a r t i c i p a n t s c o n s e c u t i v e l y 0r t0 assign a case number. One number should be assigned to each adult.

HUD-401 l8

will not be r epor t ed t o Nam e. Na mes o f p er s ons HU D. The use o f na m es is f or y our r ec or d k eepin g conv en ien ce . Relatio nship . Ente r t he appr opr iat e r elat ions hip. E xample s includ e: Se1f , Head of hous ehold, Spou s e , child. E nt r y Date . En ter dat e par t ic ipant ent er ed t he project. Usua lly th is will be t he dat e of ac t ual phys ica l mo ve -in fo r a hous ing pr ojec t . E xit Date . Ente r dat e par t ic ipant lef t t he pr oiec t. Usually this will be t he dat e t he par t ic ipant phys ica lly mo ve d out f or a hous ing pr ojec t . Do n o t includ e a p articipa nt who t em por ar ily lef t t he pr o j e c t and is expe cte d to r et ur n in les s t han 90 day s ( e.g . , hospita liza tion ). 4. In co me-e ligib le Non- hom eles s in SRO . The S R O p rog ram a llows as s is t anc e t o unit s oc c upied b y Section 8 incom e- eligible per s ons r es iding a t t h e SRO prio r to re habilit at ion. For SRO pr ojec t s on 1y, in dicate whet her t he par t ic ipant is an income -elig ible , non- hom eles s per s on ( Y) or n o t (N). SHP a nd S + C pr ojec t s s hould s k ip t his i t e m .

a. Mental illness b. Alcohol abuse c. Drug abuse d. HIV/AIDS and related diseases e. Developmental disability f. Physical disabilities g. Domestic violence h. Other (please specify) 9 b , E n t e r t h e n u m b e r o f p a r t i c i p a n t s w i t h a d i sa b i l i ty. 1 0 . P r i o r L i v i n g S i t u a t i o n . E n t e r t h e l e t t e r th a t b e st 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 th e w e e k prior to entering the project. Do not double count. a . N o n - h o u s i n g ( s t r e e t , p a r k , c a r , b u s s t a t i o n , e tc.) b. Emergency shelter c. Transitional housing for homeless persons d. Psychiatric facility* e. Substance abuse treatment facility* f. Hospital* g. Jail/prison* h. Domestic violence situation i. Living with relatives/friends j. Rental housing k. Other (please specify) *I f a p a r t i c i p a n t c a m e f r o m a n i n s t i t u t i o n b ut w a s t h e r e l e s s t h a n 3 0 d a y s a n d w a s l i v i n g on th e s t r e e t o r i n a n e m e r g e n c y s h e l t e r b e f o r e e n te r i n g th e f a c i l i t y , h e / s h e s h o u l d b e c o u n t e d i n e i t h e r th e str e e t or shelter category, as approprlate.

5a. Date o f Birth . Ent er dat e of bir t h inc ludine mon th, d ay, a nd y ear . 5b. Age . En ter a ge at ent r y . 5c. Ge nd er. Ente r appr opr iat e let t er f or gender . M-Ma le F- Fem ale. 6a. Ve tera ns Sta tus . . I ndic at e if t he par t ic ipant i s a vete ran . Ple as e not e: A v et er an is any one w h o h as ever be en o n ac t iv e m ilit ar y dut y s t at us fo r th e Unite d States . 6b. Chro nically ho m eles s per s on. I ndic at e t he n umb er of p artic ipant s t hat ar e c hr onic ally h ome less. ' 7. Ethn icity. Enter appr opr iat e let t er f or et hni c gro up . a. Hispa nic o r Lat ino b. No n-Hispa ni c or Non- Lat ino Race. En ter a ppr opr iat e let t er f or r ac e. a. Ame rica n In dian or Alas k an Nat iv e b. Asia n c. Bla ck or Afr ic an- Am er ic an d. Native Ha waiian or O t her Pac if ic I s lander e . Wh ite f. Ame rica n In dian/ Alas k an Nat iv e & W hit e g . Asian & Wh it e h . Bla ck/Africa n Am er ic an & W hit e i. American Ind ian/ Alas k an Nat iv e & Black/African Am er ic an j. Oth er Multi-R ac ial

Instructi on C odesfor P ersonsS erved W orksheet (conti nued) 1 l a.Gross Monthl y Income at P roj ect E nt r y. E nter the amountof gross monthl y i nco m et he parti ci panti s recei vi ngat entry i nto the pr oject . I l b.Gross Monthl y Income at P roj ect E xi t . Ent er the grossmonthl y i ncome the parti ci pa ntr s recei vi ngw hen exi ti ng the proj ect.
I l c . I n c o m e S o u r c e s R e c e i v e d a t P r o j e c t E n tr y. E n t e r a l l t y p e s o f a s s i s t a n c e t h e p a r t i c i pa n t i s receiving at entry to the project. a. Supplemental Security Income (SSI) b . S o c i a l S e c u r i t y D i s a b i l i t y I n s u r a n c e (SSD I) c. Social Security d. General Public Assistance e . T e m p o r a r y A i d N e e d y F a m i l i e s ( T A N F) f. StateChildren's Health InsuranceProgram (SCHIP) g. Veterans benefits h. Employment income i. Unemployment benefits j, Veterans Heaith Care k. Medicaid 1. Food Stamps m. Other (please specify) n. No Financial Resources

8.

9a. Spe cia l Ne ed s . Ent er t he let t er ( s ) f or t he ca teg ory(ies) that des c r ibe t he par t ic ipant ' s disab ility(ie s). ( You m ay double c ount ) .

25

i8 HUD-40r

1 ld. In co me So urces Rec eiv ed at Pr ojec t Ex it . En ter all type s of inc om e t he par t ic ipant is receivrng at pro jec t ex it . ( Us e c odes as in I 1 c . ) 12a Le ng th in Stay in Pr ogr am . Calc ulat ed it en . r . (See Entry Da te and Ex it Dat e abov e. . 1 12b. L en gth o f Sta y in Pr ogr am . ( Par t ic ipant di d no t lea ve d urin g t he oper at ing y ear . How lon g ha ve the y b ee n in t he pr ojec t ?) 3. Rea so n for Le av ing Pr ojec t . Ent er t he pr im a r y r ea so n why th e par t ic ipant lef t t he pr ojec t . ( Comp lete o nly f or par t ic ipant s who lef t t he pro ject a nd are not ex pec t ed t o r et ur n wit hin 9 0 days. a . Le ft for a ho us ing oppor t unit y bef or e comp letin g th e pr ogr am h . Co mnle red n r os r am c. Non -pa yme nt of r ent / oc c upanc y c har ge d. Non -co mplia nc e wit h pr ojec t e. Crimin al act iv it y / des t r uc t ion of pr oper t y / vio len ce f. Re ache d ma x im um t im e allowed in pr ojec t g. Nee ds co uld not be m et by pr ojec t h. Disa gre eme nt wit h r ules / per s ons i. De ath j. Oth er (p lea se s pec if y ) k. Un kn own /dis appear ed

of 15.S upporti ve S ervi ces. E nter al l type.s supporti veservi cesthe parti ci pantrece iveddur ing
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a. Outreach b. Case management c . L i f e s k i l l s ( o u t s i d e o f c a s e m a n a ge m e n t) d. Alcohol or drug abuse services e. Mental health services f. HIV/AIDS-related services s. Other health care services h. Education i Hnrrsinp nlacenrent : E* - l J. Emproyment asslstance k. Child care
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m. Legal n. Other (pleasespecify)

14. Destina tion ,


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Ent er t he des t inat ion of t hos e


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Perma ne nt: a . Ren tal h ous e or apar t m ent ( no s ubs idy ) b . Pub lic Hous ing c. Se ctio n 8 d . She lter Plus Car e e. HOME s ubs idiz ed hous e or apar t m en t f. Othe r subs idiz ed hous e or apar t m ent g. Home ow ner s hip h . Moved in wit h f am ily or f r iends Tran sitio na l: - i. Tran sitio nal hous ing f or hom eles s per s o n s j. Mo ve d in wit h f am ily or f r iends In stitu tion : k. Psychia t r ic hos pit al. l. In pa tien t alc ohol or dr ug t r eat m ent f ac i l i t y m. Ja il/prison Eme rge ncy: n . Emerg en c y s helt er Oth e r: o . Othe r suppor t iv e hous ing. p. Places n ot m eant f or hum an habit at ion (e.g ., stree t ) q . Othe r (p leas e s pec if y ) Un kn orvn: r. Un kn ow n

26

IruD-4O1 l8

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