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MHDC - Juan Pifarre 06

MHDC - Juan Pifarre 06

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(exp.07/31/2006) OMB Approval 2506-0145 No.

U. S. Department of Housing and Urban Development Office of Community Pianning and Develooment


Annual Progress Report (APR)
for Supportive Housing Program Shelter Plus Care and Section8 Moderate Rehabilitation for SingleRoom Occupancy Dwellings (SRO) Program

formHUD-401 (08/2003) 18

including the time for reviewing lnstructlons, Public reporting trurden for this collection ofinformation is estimatedto average33 hoursper response, Thi sagenc y may s earch 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 on. not conductor and a person is not required to respondto, a coliectionofinformation unlessthat collectiondisplaysa valid OMB control number. lpglot,


Generallnstructions Purpose. The Annual Progress Report (APR) tracksprogramprogressand accomplishments the Departrnent's in competitive homeless prograns. assistance Filing Requirements. Recipientsof HUD's homeless assistance erants must submit 2 APR'S to I{UD within 90 days after the end of each operating year. One copy of the repofi must be submittedto the CPD Division Director in the local HUD Field Office responsiblefor managing the grant. The other copy must be submitted to HIID Headquarters,Deparlment of Housing and Urban Development,Atfn: APR Data Editor, Room7262,451 lth Street,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 submit an APR 90 days after the end of the first operating year and any year in which they use SHP funding for leasing, supportive services,or operations. For years in which they do not receive SHP funding, they must submit an Amual Certification of Continued Project Operation throughout the 20 years. The certification can be found at the back of this APR. A separatereport must be submrtted for each HUD grant received. For Shelter Plus Care, a separate APR must be submitted for each Shelter Plus Care component. For thosegrantees receivingan extension,a separate report coveringthat 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 computerizedsystem to store and tabulate the information. The worksheetsshould not be submitted to HUD u.ith the APR. Organization of the Report. The APR is organized in the following manner: Part I: Project Progress. This poftion of the reporl describes progressin moving homeless the persons self-sufficiency, to services received, project goals,and beds created. Part II: Financial Information. and SRO. This portion of the report is completedby all granteesreceiving funding under SHP, S+C

Final Assembly of Report. After the entire report is assembled, number every page sequentially. Mark any questionsthat do not apply to your programwith "N/A" for not applicable. (SeeSpecialInstructionsfor SSO Projectsbelow.) Definitions. The following terms are used in the APR. As indicated, in some cases,terms are applied differently depending on whether the funding is from SHP, S+C, or SRO. personas "an unaccompanied Chronically homelessperson - HUD definesa chronicallyhomeless homelessindividual with a drsabling condition who has either been continuously homelessfor a year or more OR has had at leastfour (4) episodesof homelessness the past three (3) years." To be considered in chronicallyhomeless a personmust havebeen on the streetsor in an emergency shelter(i.e.nottransitionalhousing)during thesestays. Disabling condition - HUD defines"disabling condition" as "a diagnosable substance disorder,serious use mental illness, developmentaldisabiiity, or chronic physical illness or disability, including the co-occurrenceof fwo or more of theseconditions." Entered the program for S+C and SRO projectsmeanswhen the parlicipant stafisto receiverental assistance. For S+c and selvices provided prior to this point are recognized as necessaryfor outreach./enrollment are eligible to count as match. An Extension APR appiies to SHP and S+C granteesthat requestedand received an extensionof their grant term from the HUD field office. The only difference between an APR for the extension period and the regular APR (besidesthe formHUD401I (08/2003) 1

arnountof time covered) is the signaturepage. Granteesshould circle "yes" to indicate the APR is for an extension period and circle the operating year for which the report is an extension.For example, if the grantee is extendrngyear 3, the granteesliouid submit an APR as usual for year 3 and submrt another APR for the extension period, indicating the secondis an extension and aiso cucling year 3 on the signature page. Family meansa householdcomposedof two or more relatedpersons,at leastone of whom is an adult. Caregivers are not reportedon in the APR. Grantee meansa direct recipient of the HUD award. Left the program for S+C projectsmeanswhen the participantstopsreceivingrental assistance is not expectedto and returx to S+C assisted housing. If the participantretumsto S+C assisted housingwithrn 90 days, the personshould not be considered exiting from the program. If the personreturrrsto S+C assisted as housing after 90 days,that personis considereda new parlicipant. The worksheet is designedto capture this information. Match for S+C meansthe value of supportive servicesreceived by participants in the S+C project which, in the aggregate, must at leastequalthe value of the S+C rental assistance provided over the life of the project. For SHp, match meanscashused to provide the grantee'sportion of acquisition, rehabilitation, new construction, operationsand supportiveservices expenses. Operating year for SHP meansthe date when participants begin to receive housing and./orservices. The first operating year begins after developmentactivities for acquisition, rehabilitation, and new construction are complete, after a copy of the Certificate of Occupancy is sent to the local HUD office, and when the first participant is acceptedinto the project. For projects without acquisition, rehabilitation, or new construction, the operating starl date begins when the grantee acceptsthe frrst participant. For S+C (SRA, PRA and TRA components),the first operating year begins on the date HUD signs the grant agreement. For S+C/SRO and for Sec. 8 SRO, the first operating year begins with the effective date of the Housing AssistancePalments (HAP) Contract. To determinewhich operating year to circle on the APR cover page, begin counting flom the initial grant operating srarr date and include renewals grants. For example, a project receiving an imtial grant for three years and a renewal grant for two years would circle years 1, 2, and 3 respectively on the APR cover sheetfor 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. Participant means single persons and adults in families who received assistance during the operating year. 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 Proiects. SSO grantees should completeall questions, unlessa written agreementhas been reachedwith the freld office concerning which questions can be answeredusing estimates,or in rare instances, skipped. Below is an exampleof how information could be derived in a large, single-seruice SSO project: A grantee/sponsor staff member could be assignedto collect information from the organizationshousing the participants. The staff person would contact theseindividual organizationsto requestinformation regarding the persons in that facility that use the serviee"For participants living on the street,the grantee/projectsponsormay provide estimates. Information could be collectedfor eachparticipantor for pat'ricipants receivingservicesat a point-in-time. If estimates or point-in-time counts are used, the method used must be describedin the APR and the documentationkept on file. As with all projectsfundedunder HUD's homelessness assistance grants,grantees operatingSSO projectsare expected to 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 assistinghorneiesspersonsobtain/remain in permanent housrtrgand increasetheir skills and income. The APR documents their progressin meetingthesegoals.

formHUD401 (08/2003) 18

In some circumstances field offices and granteesmay sign a $Titten agreementconceming questionswhich can be answered using estimates, in rare instances, or skipped. Below are someconsiderations reportingon particulart)?es of projects: for Outreach Only Proiects. - Projectswhich are solely devotedto streetoutreachand comection to housingand services are not required to track participants beyond their contact with personson the street. It is sufficient for theseprol ects to enter inforrnationon questionsi - 10 (skippingquestions11- 13 and 17). Estimates for questions 5 -9 are allowed, given that parlicipants may be reluctant to answerpersonal questions. Answering the questionswill demonsfratethat the granteeis serving the appropriate number of people, providing basic demographic information for Congress,demonstratingthat homelesspersonsare being served,demonstratingthe [pes of housing parlicipants are conaectedto, and the type of servicesthey aie receiving. Hotline Proiects. - Hotline services similar to outreach are projects,but contactbetweengranteeand participantis often of very short duration - people enter and leave the program nearly simultaneously. It is suffrcient for theseprojecis to answer questions1-5 (skipping4), 10, and 14-19(skipping l7). -P roj ectsthatprovi dechi 1dcare,afterschool care,counselingf or children, etc. make an important contribution toward moving-a family out of homelessness. While the main focus of the pro;ect is providing servicesto the children, it is the adults who are reported on in questions6-16 of the ApR. Like all other proJects, this type is also targetedtoward getting the families into housing and increaiing the families, incomes. Granteesmay skip question 9; a1lother questionsshould be answered(except 17).


l. and


housing and increasetheir skills and incomes. It is sufficient for theseprojects to enter informatron on questions 1-10 and 1, n questions 1-10and 1419 (question 17 may be skipped). However, with transportationservicis, it is unreasonable think to that someonewould have to give their age, race, and ethnicify to a bus driver to get a ride a few blocks. For these services,provide a narrative, which gives the mrmber of rides given during the operating year, and provides estimates on the above statisticsbased on the population that utilizes the service. Spqcial Instructions For Safe Haven (SH) Proiects. - Granteesare remindedthat they are to report ONLy on the number of participants the application was approved for (cannot exceed25 participants).

oursrv rwr vtLv ur r4ury ruurr. uurauurr rosuseo ONLY m0lfectly On asslshng single service of fairly shorl duration focused L-r-L\LY indirecily on assistingho*.l.* p*ron, to homeless perSOnS to obtain/remain in permanent Obtain/remain in pefmanent

ice P


S^ - ^

^ r ^ ft6 6 -



elessMana Informa HMIS - HMIS granteesshould fil1 out the cover sheet of the APR (marking HMIS at the bottom) and part II Financial Information. The APR also has a sheetthat lists HMIS acnvltres.

form HUD-401I (08/2003) 1


CityandCounty San Francisco of
Project Sponsor:

HUD Grantor ProjectNumber: cAo1c501036 ProjectName:

Mjssion Development Housing Corporation
yearbeingreported Operafing Year: (Circlethe operating on)

Apartments JuanPifarre
Reporting Period; (monttr/day/year)

I n2 tr3 El+ Ds no Jt []r Ds Dro Dr r n r z D r : f l r q fl rs fl ro l rz l ra [rs l zo
Indicate extension; ! Yes X No if Indicate renewal: if X Yes n No Prevrous Numbers thisproiect: Grant for



cA01 c301045

Checkthecomponent the programon which you arereporting. for

SupportiveHousingProgram (SIf) f [ D fl f

ShelterPIus Care {S+C) fl X I n Tenant-based (TRA) Rental Assistance (SRA) Sponsor-based RentalAssistance (PRA) Project-based RentalAssistance (SRO) Single RoomOccupancy

Section ModerateRehabilitation 8 I SingleRoom Occupancy (Sec. SRO) 8

Transitional Housing lermanentHousingfor Homeless Persons with Disabilities SafeHaven tnnovativeSupportive Housing Supportive Services Only

Summary of the project: (Oneor two sentences a description population,numberserveri with of and accomplishments operatingyear) this

year, project provided to threeunitsof permanent During operating this this up housing homeless to families, of All theparticipants f romlhe streets emergency were or and shelters are living withoneor morespecial needs relaed to mental health, substance ab(use), HIV/AIDS. and/or
questions Name& Title ofthe Person who can answer aboutthis report:
Phone: (include area code)

MalikLooper, ChiefOperating Officer

Fax Number:(includearea code)

Mission Housing Development Corporation 474 Valencia Street, Suite280 SanFrancisco, 94103 CA


I herebycertify that ali the informationstatedherein is true and accurate.
Warning: HUD will prosecute falseclaimsandstatements. Convictionmay resultin criminal 1 0 1 0, 1012r U. S . C .3 7 2 9 ,3 8 4 2 3l
Name& Title of AuthorizedGrantee Official: Signature Date: &

i8 u.s.c

Adviento, Prosram Grants SHP/S+C & A
NameandTitle of AuthorizdProject Sponsor Official:

Malik Looper, Chief Operating Officer

x ^"..\p=WN}:a\\a
formHUD-401 (08/2003) 18

Sisnature Date: &


1. ProjectedLevel of Personsto be servedat a given point in time. (fromthe application, SHPSec. SPCF; Sec. D; SRO- Sec.D)
Number of SinglesNot i n Fami l i es Number of Adults in Families Number of Children i n Fami l i es Number of Families a

Proiccted Level

Persons beserved a givenpointin time to at Persons Served during the operating year.
Number of SinglesNot in Farnilies Number of Adults in Families Number of Children in Fanri'lies


Number of Families


Number on the first day of the operatingyear year Numberentering programduring the operating





year Number who left theprogram duringtheoperating
Number in the program on the last day of the operatingyear (a +b -c)=d






Project Capacity.
Number of SinglesNot in Families

Number of Adultsin Families

Nunrber of Children in Fami l i es

Number of Families

Number on the last day (from 2d, columns 1 and 4) b.

Number proposedin application (from l a, columns I and 4) CapacityRate (divide aby b): % %


100 %


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

personswere housedby the SRO program during the operatingyear? How many income-eligiblenon-homeless


Age and Gender. Of those who entered the project during the operating year, how many people are in the following age and gendercategories? (from 2b, column1) SinglePersons

Ase 62 and over



b. d

51-61 31-50 I 8-30
17 and under

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

i h

62 and over

5l - 6l

31- s0
l 8-30
l 3- t I


o- Iz


l -5 UnderI

formHUD-401 (08/2003) 18

Answer questions - 10 only for participants who entered the project during the operating year (from 2b, columns 6 | & 2). The term participant meanssinglepersonsand adultsin famrlies. It doesnot include children or caregivers.NOTE: The total for questions, 8 and 10 below shouldbe the same;respondto eachof thosequestions all participants. 7, for Someof the questionslisted throughout the APR will be asking information for individuals who are chronicallv homeless.
6a. Veterans Status. A veteranis anyonewho has ever been on activemilitary duty status. How many participantswere veterans? 6b' chronically homelessperson' An unaccompanied homelessrndividual with a disabling condition who has either been continuously homeless a year or more oR has had at leastfour (4) episodes for ofhomelessness the past three (3) years. To be considered in chronically homeless a person must have been on the streets or in an emergency shelter (i.e. not transitionai housing) during these stays. How many participantswere chronically homelessindividuals? 7,

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

b. 8.


b. c d. f.

Bl acklAfiican American Nat ve Hawaiian/OtherPacific Islander wh te American Indian/Alaskan Native & White

Asian& White
Black/African American & White American Indian/Alaskan Native & Black/African American


9a' Special Needs' How many participantshave the following? Participants may have more than one Ifso, count them in all applicablecategories.For eachcondition, aiso indicatethe number that were chronically homeless.



c. d.

Mental illness Alcohol abuse

HIV/AIDS and relateddiseases Developmentaldisability Physical isa bi it y d I Domestic violence Othgr (pleasespecify)



9b. How many of the participantsare disabled?


formHUD-40118 (08/2003)

the in 10. Prior Living Situation.How manyparticipants sleptin thefollowingplaces theweekpriorto entering project? (Foreach (Choose participant, participants in thefollowing places. homeless slept Choose place). Also,indicate one how manychronically one)
All a.


c. d. f. e h.

park,car,bus station, (street, Non-housin.q etc.) Emergency shelter persons Transitional housingfor homeless Psvchiatric laciiitv* Substance abusetreatmentfacilitv+ Hospital* * Jail/prison Domesticviolence situation Livine with relatives/friends

Rental housins

Other (pleasespecify)

*If a participant came from an institution wasthere but less than30 daysandwasliving on thestreet in or emergency shelter before the be entering treatment facility,he/she should counted eitherthe in street shelter or cal.egory, appropnate. as

Completequestions11 - l5 for all participants who left during the operating year (from 2c, columns 1 and 2). The term participant meanssingle persons and adults in families. It doesnot include children or caregivers. The term chronically homelessperson meansan unaccompanied homeless individual with a disablingconditionwho has eitherbeencontinuously homeless a year or more OR has had at leastfour (4) episodes homelessness the past three(3) years.To be considered for in of chronically homelessa person must have been on the streetsor in an emergencyshelter (i.e. not transitional housing) during thesestays. participants left duringtheoperating year, who 11. Amount and Source Monthly Incomeat Entry and at Exit. Of those how many of place monthlyincome participants at each of the leveland each were monthlyincome levelandwith each source income? Also,please persons thesecond in source income chronicallyhomeless of for in columnof each chart.Thenumber participants ChartA andB of should thesame. be
All A. Monthlv Income at Entrv No income Chmnic C. Income Sources Entry At Supplemental Securitylncome (SSI) b. All Chronic


sr 1s0
sr51 $250 5500 $251$501 $i, 00 0

(SSDI) Security Disability Income Social Social Security
GeneralPublic Assistance TemporaryAid to Need;rFamilies(TANF) Program(SCHIP) StateChildren's Health Insurance VeteransBenefits EmPlol'rnentIncome UnemolovmentBenefits VeteransHealth Care Medlcaid




$100r$1500 $r501s2000 + s2001




m n.

Food Stamps
Other (pleasespecify) No FinancialResources

formHUD401 (08/2003) 18

Arl Chronic
B. Mo nth ly I nc om eat Ex it

D. Income Sources Exit at


No income

Supplemental SecurityIncome (SSI) Social SecurityDisability Income (SSDD


$1- 150

b. c.

s15t- $250

General Public Assistance TemporaryAid to Needy Families (TANF)


$s0i- s1,000

$1001- 15 0 0 s $1501- 0 0 520 + $2001


StateChildren's Health InsuranceProgram (SCHIP)

Veterans Benefits
Employrnent Income Unempl or,,rnent enefits B




Veterans Health Care Medicaid Food Stamps

m n.

No FinancialResources

12a. Length of Stay in Program. Of thoseparticipantswho left during the operating year (from 2c, columns 1 and 2), how many were in tLf^- +L^ following lengths rrru --^i^^+ rwr r,,r of time? Also, pleaseplacethe length ofstay for chronically homelesspersonsin the second P,uJrrr column. AII


Lessthan 1 month

c. d.

1 to 2 months 3 6 months
7 months- 12 months l3 months - 24 months 2 5mo nth s - 3y ear s 4 ve ars-5v ear s 6 ve ars-Tv ear s 8yea rs-l 0y ear s




l2b. Length of Stay in Program. For thoseparticipantsthat did not leave during the operatingyear (from 2d, columns 1 and 2), how long have they been in the project? Also, pleaseplace the length ofstay for chronically homelesspersonsin the secondcolumn. All



d f. h

Less than 1 month I to 2 months 3 - 6 months 7 months - 12 nronths

13months 24 months 2 5mo nth s - 3y ear s 4vea rs-5 v ear s 6 ye ars-Ty ear s 8 vears- 10 vears Over 10 years





formHUD-401 (08/2003) 18

13.Reasons Leaving. Of those for participants !e:[t project year who the duringtheoperating (from2c, columns and2), howmany 1 q1fithe primaryredsotl.Also,please left for thefollowing reasons? a participant for multiple If left ittchrde place reasons, the primary reason chronically persons thesecond homeless in for colun'ln.
All Left for a housing opportunitybeforecompletingprogram b. Completedprogram Non-pay'rnentof rent/occupancycharge


Non-compliancewith proj ect Criminal activity / destructionofproperty/ violence Reached maximum time allowed in proiect Needscould not be met by project Disagreement with rules/persons Death




Other(please specify)


14. Destination. Of thoseparticipantswho left during the operatingyear (from 2c, columns 1 and 2), how many left for the following destination? Also, pleaseplacethe destinationof chronically homelesspersonsin the secondcolumn. All PERMANENT (a-h) (no Rentalhouseor apartment subsidy) Chronic


Public Housing Section 8
ShelterPlus Care HOME subsidized houseor aDartment


Other subsidized house or apartment Homeownership Moved in with family or friends persons Transitionalhousing for homeless



Movedin with family or friends
Psychiatrichospital Inpatient alcohol or other drug heatment facility



Jail/prison EMERGENCYSHELTER(n) OTHER(o-q) p.
q. n.

Emergency shelter Othersupportive housing
Placesnot meantfor human habitation(e.g. street)

(please Other specify)
[) deceased Unknown



formHUD-401 (08/2003) 1I

15. SupportiveServices.Of thoseparticipants who left duringthe operating year(from 2, columnsI and2), how manyreceived the followingsupportive services duringtheirtimein theproject? Also,please place supportive the services received chronically for homeless participants left duringtheoperating in thesecond who year column.



Outreach b
d. e f.

Case management Life skills(outside case of management) Alcohol drusabuse or services
Mental health services HIV/AIDS-related services Other health care services Education Housing placemenl Employnent assistance Child care Transportation



m. n.


Other(please specify)
1) residentialmanagement services

formHUD401 (08/2003) 18

Technical year for objectives this operating (fromyourapplication, list 16. overall programGoals. Underobjectives, yourmeasurable your progress meeting objectives. the in describe or Submission, APR) for eachof thethreegoalslistedbelow. UnderProgress, year, for objectives thenextoperating the Year'sObjectives, specify measurable NextOperating Under a. ResidentialStability Objective: 660/o participants will remain in Shelter Plus Care housing for at least one year. of

Progress: Exceeded. All participants remained in housing for at least one year.

NextOperatrng Year'sObjectives:66%oparticrpants of will remain in ShelterPlus Care housingfor at leastone year.

Objective: 66Yoof participants will remain in Shelter Plus Care housing for at least two years.

Progress: Exceeded. A1l participants remained in housing for at least two years.

Next Operating Year'sObjectives: 66%o participants will remain in Shelter Plus Care housing for at least two years. of


Increased Skillsor Income Objective: 33o/o participants will either enter or continue part - or full-time employment during the operating of year.

Progress: During the operating year all participants enteredor continued part or full-time employment.

Next Operating Year'sObjectives:33o/o parlicipants will either enter or continue part - or full-time employnent of during the operating year. Objective: 33o/o participants will either enter or continue an educational and,/orvocational training program dunng the of operatingyear.

Progress: None ofthe participants either enteredor continue in educational and/or vocational training during the operating year. However, participants remain engagedin on-site volunteer activities.

NextOperating Year'sObjectives of and/orvocationaltraining 33%o participantswill either enteror continuean educational program during the operating year.


GreaterSelf-determination Objective: 33% of those with drug and/or alcohol addiction will be clean and sober.

Progress:Exceeded. All participants remained clean and sober.

Next OperatingYear's Objectives:33% of thosewith drug and/or alcohol addictionwill be cleanand sober.

formHUD-401 (08/2003) 18

Objective: 66%o householdswho need to reunify with their children, will be reunited wrth their children by placement of in Shelter Plus CarehousinE.

Progress:Exceeded. None of the participants neededto reunifu with their children.

Next Operating Year's Objective: 660% householdswho need to reunify with their children, will be reunited with their of childrenby placementin ShelterPlus Carehousing. Objective: 660/oofparticipant parents will retain custody of, and care for, their children.

Progress:Exceeded. Exceeded. A11participant parentsretained custody of, and care for, their children.

Next Operating Year's Objectives: 660/o participant parents will retain custody of, and care for, their children. of

17.Beds. SHPrecipientsanswerlTa. S+CrecipientsanswerlTb. SROrecipientsanswerlTc. (SIIP-,SSOprojectsdo not complete tltis question)
a. SHP. How many bedswere included in the applicationapprovedfor llrls project under 'Current Level' and under 'New Effort'? How many of these New Effort beds were actually in place at the end of the operating year? Cunent Level New Effort New Effort in place Numberof Beds: S+C' How many beds and dwelling units were being assisted with project funds at the end of the operatingyear? (Include beds for all participants, other family members,and care givers.) Number of Beds: Number of Dwelline Units: c. 3 3


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

1a IJ

formHUD4018 (08/2003) 1

Part II: Financial Information
18. Supportive Services. For SuoportiveHousine (SHP), this exhibit provides information to HUD on how SHP funding for supportiveservices was spentduring the operating year. Enter the amount ofSHP funding spenton thesesupportiveservices. Include HMIS costs under "Other". For ShelterPlus Care(S+C), this exhibit tracksthe supportiveservices match requirement. Specify the value ofsupportive services from all sources that can be countedas match that ali 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 information to HUD on the value of supportiveservices receivedby homeless personsduring the operating year.

Outreach b. c d. Case management Life skills (outsideof casemanagement) Alcohol and drue abuse services Mental health services f.


$ 5,000
$ 4,849 $ 10,995

AIDS-relatedservices Other health careservices Education


placement Housing
Emplovment assistance Child care Transportation Legal


l. m. n.

Other (pleasespecify) 1) 2) 3) Food Residentialmanagement Acupuncture and massage

$ 1,800 $ 75,887 $ 4,800 $ 103,331 $ 103,331


TOTAL (Sum of a through n)

Cumulativeamountof match provided to date for the Shelter PIus Care Program under this grant

18 formHUD-40'l (08/2003)

19. Supportive Housing progran: Leasing, Supportive Services,Operating Costs,HMIS Activities and Administration year.Forexpansion each operating these charts mustcomplete Program Housing under Supportive the funding All grantees receiving projects:IfSHPgrantfundsarefortheexpansionofapre-existinghomelessfacility,onlythepeopleandexpendituresfortheadditional Documentation resources is not required be of used to application anygrantamendments. or as expansion be included, in theoriginal may any made inspection HUD andAuditors.Do not include expenditures by with thisreport should kepton file for possible be submitted bui the wasexecuted. before SHPerant
Summary of Expenditures. Enter the amountof SHP grant funds and cashmatch expendeddu ing the operatingyear for eachactivity. total should be the sameas the SHP supportive This table should add up both horizontally and vertically. The SHP supportiveservices ln servlces Total Expenditures SHPFunds


Operating Costs
HMIS Activities

Note: Pa).rnents principal and intereston any loan or mortgagemay not be shown as an operatlngexpense. of

Sources of Cash Match. Enter the sourcesof cashidentified in the CashMatch column, above,in the following as catesories. Use additionalsheets, necessary. Amount Grantee/project sponsor cash b Local government(pleasespecify)

Stategovernment (pleasespecify)


Federalgovernment(pleasespecify) CornmunityDevelopmentBlock Grant (CDBG)



(pleasespecify) Privatecashresources


Occupancycharge/ fees Total



formHUD401 (08/2003) 18

20. Supportive Housing Program: Acquisition, Rehabilitation, and New Construction must these charts theyearoneAPR in or All grantees received that rehabilitation, newconstruction complete SHPfundsfor acquisition, to equally match amount SHPfunds will demonstrate HUD thatthegrantee contributed to enough cash at least the of only. Thisexhibit has spent acquisition, for that wereprovided not required be submitted rehabilitation, newconstruction. or Documentation matching funds is to with thisreport should keoton file for oossible but be insoection HUD andAuditors. bv
Summary of Expenditures. Enter the amountof SHP grant funds and cashmatch expended during the operatingyear for eachactrvity. SHP Funds


Total Expenditures

Acquisition Rehabilitation New construction Total


Cash Match. Enter the sources cash identified in the CashMatch column, above,in the following categories. Use of additional sheets, necessary. as

Grantee/projectsponsor cash


Local govemment (please specify)

State government (please specify)


Federal government (pleasespecify) Communitv DeveloomentBlock Grant (CDBG)



(please Private cash resources specify)


Occupancycharge/fees Total


formHUD-401 (08/2003) 1I

21. For SupportiveHousins (SHP) - HMIS Activities This exhibit providesinformation to HUD on horv SHP-HMIS funding for supportivesen'rces \\,asspentduring the operating year. Enter the amountof SHP-HMIS fundinesDent theseactivities. on

HMIS Activities Only


Central Server(s) PersonalComoutersand Printers Nefworking Securifv Subtotul Software/ User Licensine SoffwareInstallation Support and Maintenance SupportingSoftwareTools Subtotal

Trainins bv Third Parties Hostine / Technical Servrces Programming: Customization Prograrnmins:SvstemInterface Prosramrning: Data Conversron SecurityAssessment and Setup On-line Corurectivity (InternetAccess) Facilitation Disasterand Recoverv Subtotal

ProjectManagement Coordination / DataAnalysis Programming TechnicalAssistance and Trainins Adnrinish'ative Support Staff Subtotal


Space Costs


OperationaiCosts Total

formHUD4018 (08/2003) 1

Describeany problems and/or changesimprementedduring the operating year.

Technical Assistanceand Recommendations Basedon your experience during the last year' are there any areasin which you need technicaladviceor assistance? Ifso, pleasedescribe.

ourcPDLpresentative isaccessibl" ,".ponds uni quickry knowredseabry and to }ij?rh""|!n*Un?:f|f;JrTice'

The san Francisco shelter Plus care Programcontinuesto enjoy a very productive and cooperative relationship

formHUD4018 (08/2003) 1

ProiectOperation Annual Cerffication of Continued

Program Supportive Housing

ProjectNumber: ProjectName: OperatingStartDate:
Grantees that receivedSupporliveHousing Programfunding for new construction,acquisition,or rehabilitation are required to operatetheir facilities for 20 years.


certify that the facility that for receivedassistance acquisition,rehabilitation,or new constructionfrom the personsfrom SupportiveHousing Programhas operatedas a facility to assisthomeless numberof . * I also certify that the grantis still serving to

(mo/yr) persons at


(site address) are of and all the requirements the grantagreement being satisfied.

(Signafure) (Title)

(Dateof Certification)
*Current Year 19
(08/2003) formHUD40118

PersotrsServedWorksheet - HUD Arylual Progress Report
This workshe€!is oplional and is intendedto help you collect infomation needed completethe Annual Progrss R€pon. Instructionssd Codes to HUD.
Number of Months in Project (calculate)
tL l

Number of Months in Project -Participant did not leave (calculate) 12b

New Participanl (Y /N )

18 form HUD-401 (oBl2oo3)

Persons Served Worksheet (continued)
Do not submit this worksheetto HUD
No. Veterans Status (Y/N) oa Chronically Homeless (Y,'l.i) 6b Ethnicity (code) 7 Race (code) 8 SpecialNeeds (code) 9a SpecialNeeds (code) 9b Prior I i vi no Situation (code ) 10 Monthly Income At Project Entry i 1a Monthly Income At Project Exit 11b Income Soulces At Entry (code) 11c IncomeSources At Exit (code) 1l d

form HUD401 1I (OB/2003)

PersonsServedWorksheet (continued)
Do not submit this worksheet HUD to
No Reason for Leaving Program (code) l3 Destination (code) t4 SupportiveServices (code) l5 Notes

form HUD401 18 (OBl2o03)

Instructions Codes Persons and for Served Worksheet
T he u se of this wor k s heet is opt ional. I t was des i g n e d to help you colle ct inf or m at ion on par t ic ipant s n e e d e d to comp lete th e Annual Pr ogr es s Repor t . I f t he w orksh ee t is u pd ated as par t ic ipant s m ov e in and m o v e out o f you r p roje ct, m os t of t he inf or m at ion r equ i r e d for co mple tion will be c ont ained in t he wor k s hee t . D o not sub mit this wo r k s heet wit h t he APR. F or p roje cts th at ser v e f am ilies , HUD only r equi r e s reportin g on the nu m ber of c hildr en s er v ed, and t h e age a nd ge nd er o f thes e c hildr en. O nly nam e, rela tio nship , da te of bir t h, and age on t he wor k s h e e t need to be comp leted f or c hildr en. As s ign t he a d u l t s a num b er, b ut no t e ac h f am ily m em ber . Us e t his n u m b e r to tran sfe r to the o t her pages of t he wor k s heet . B eg in nin g with n um ber 4, t he num ber s in t he c ol u m n s ref er to th e q ue stio ns on t he APR f or m . I f any ques tion s a re an sw er ed wit h "O t her , " pleas e ent e r t h e specific "Oth er" an s wer f or inc lus ion in t he APR . P articip an t Numb er . This c olum n allows y ou t o e ith er n umb er. p ar t ic ipant s c ons ec ut iv ely or t o assign a case nu mber . O ne num ber s hould be assisn ed to e ach a dult . Nam e . Na mes o f p er s ons will not be r epor t ed t o H UD. The use of n am es is f or y our r ec or d k eepin g conve nle n ce. R elation sh ip. Ente r t he appr opr iat e r elat ions hip . E xample s in clu de : Self , Head of hous ehold, Spo u s e , child. E nt r y Date . Ente r dat e par t ic ipant ent er ed t he project. Usu ally this will be t he dat e of ac t ual physica l mo ve -in for a hous ing pr ojec t . E xit Da te. En ter d at e par t ic ipant lef t t he pr oject . Usually th is will b e t he dat e t he par t ic ipant phys ica lly mo ve d o ut f or a hous ing pr ojec t . Do n o t inclu de 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 . h o sp ita l iza 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 Se ctio n 8 incom e- eligible per s ons r es iding a t t h e SRO p rior to rehabilit at ion. For SR. O pr ojec ts o nly, ind ica te whet her t he par t ic ipant is an in co me-e ligib ie, non- hom eles s per s on ( Y) or n o t (N). SHF a nd S + C pr ojec t s s hould s k ip t his i t e m .

6 a . V e t e r a n s S t a t u s . I n d i c a t e r f t h e p a r t r c ip a n t i s a veteran. Please note: A reteran is anyone who h a s e v e r b e e n o n a c t i v e n t i l i t a r y d u t y s t a tu s fo r the United States. 6 b . C h r o n c a l l y h o m e l e s s p e r s o n . I n d i c a t e th e number of participants that are chronically homeless. 1. E t h n i c i t y . E n t e r a p p r o p r i a t e l e t t e r f o r e th n i c group. a. Hispanic or Latrno b. Non-Hispanic or Non-Latino Race. Enter appropriate letter for race. a. American Indian or Alaskan Native b. Asian c. Black or African-American d. Native Hawaiian or Other Pacific Islander e . Wh i t e f . A m e r i c a n I n d i a n / A l a s k a n N a t i v e & W h i te g . A s i a n & Wh i t e h . B l a c k / A f r i c a n A m e r i c a n & Wh i t e i. American Indian/Alaskan Native & Black/African American j. Other Multi-Racial


9a. Special Needs. Enter the letter(s) for the c a t e g o r y ( i e s ) t h a t d e s c r i b e t h e p a r t i c i p a n t's disability(ies). (You may double count). a. Mental illness b. Alcohol abuse c. Drug abuse d. HIV/AIDS and related diseases e. Developmental disability f. Physical disabilities g. Domestic violence h. Other (please specify) 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 b 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 appropriare.

5a. Date of Einth . Ent er dat e of bir t h inc ludins mon ih, d ay" an d y ear . 5b. Ag e. Ente r ag e at ent r y . 5c. Gen de r. Ente r appr opr iat e let t er f or gender . M -Male F- Fe m ale.

formHUD-401 (08/2003r 18

In stru c t ion Codesfo r Pe rs o n sSe rv e d Wo rk s heet ( c ont inu e d )
I I a. Gro ss Mo nth ly I nc om e at Pr ojec t Ent r y . Ente r th e a mou nt of gr os s m ont hly inc om e t he pa rticip an t is re c eiv ing at ent r y int o t he pr oje c t . I lb. Gro ss Mo nth ly I nc om e at Pr ojec t Ex it . Ent e r the g ross mo nth ly inc om e t he par t ic ipant t s receiving wh en ex it ing t he pr ojec t . I lc.Income So urces Rec eiv ed at Pr ojec t Ent r y . Ente r all type s o f as s is t anc e t he par t ic ipant is receiving a t e ntr y t o t he pr ojec t . a. Sup ple men tal Sec ur it y I nc om e ( SSI ) b . So cia l Securi t y Dis abilit y I ns ur anc e ( SSDI) c. Social Se cu rit y d. Ge ne ral Pu bli c As s is t anc e e. Temp ora ry Aid Needy Fam ilies ( TANF) f. StateChildren's Health InsuranceProgram(SCHIP) g. Ve tera ns be nef it s h. Emplo yme nt inc om e i. Une mplo yme nt benef it s j. Vete ran s He al t h Car e k. Me dicaid l. Fo od Sta mps m . Othe r (p lea s e s pec if y ) n. No Fina ncial Res our c es i lld. I nco me Sou rce s Rec eiv ed at Pr ojec t Ex it . Ente r all type s o f inc om e t he par t ic ipant is receiving a t pro jec t ex it . ( Us e c odes as in i 1c . )


D e s t i n a t i o n . E n t e r t h e d e s t i n a t i o n o f t h o se leaving the project. Permanent: a , R e n t a l h o u s e o r a p a r t m e n t ( n o s u b si d y) b. Public Housing c. Section 8 d. Shelter Plus Care e . H O M E s u b s i d i z e d h o u s e o r a p a r t me n t f. Other subsidized house or apartment g. Homeownership h. Moved in with family or friends T ran sitional: i . T r a n s i t i o n a l h o u s i n g f o r h o m e l e s s p e r so n s j. Moved in with family or fricnds I n stituti on: k. Psychiatric hospital. l . I n p a t i e n t a l c o h o l o r d r u g t r e a t m e n t fa ci l i ty m. Jail/prison Emergency l n. Emergency shelter Other: o. Other supportive housing. p . P l a c e s n o t m e a n t f o r h u m a n h a b i t a ti o n (e,9., street) . q. Other (please specify) Unknown: r. Unknown

l 2 a L engt h in S t ay i n Pro g ra m. C a l c u l a te di te m . (S ee E nt r v Dat e a n d E x i t D a te a b o v e .)
l2b. Le ng th of Sta y in Pr ogr am . ( Par t ic ipant did n ot 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 ?) 13. Rea so n fo r Le av ing Pr ojec t . Ent er t he pr im a r y rea so n wh y th e p ar 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 proje ct a nd are not ex pec t ed t o r et ur n wit hin 9 0 days. a. Le ft for a h ou s ing oppor t unit y bef or e c omp letin g th e p r ogr am b. Comp lete d pr ogr am c . No n-p aymen t of r ent / oc c upanc y c har ge d. No n-comp lian c e wit h pr ojec t e. Crimina l activ it y / des t r uc t ion of pr oper t y / vi ol e n ce f . Rea ch ed ma xi m um t im e allowed in pr ojec t g. Ne ed s co uld n ot be m et by pr ojec t h. Disag ree men t wit h r ules / per s ons i. Dea th j. Othe r (p lea se s pec if y ) k. Un kn own /disappear ed

15. Supportive Services. Enter all types of s u p p o r t i v e s e r v i c e s t h e p a r t i c i p a n t r e c e i ve d d u r i n g the time in the project. 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 g em e n t) d. Alcohol or drug abuse services e. Mental health services f. HIV/AIDS-related services
o Other heal th ggpg s er v i c es

h. Education i. Housing placement j. Employment assistance k. Child care L Transportation m. Legal n. Other (pleasespecify)


form HUD40118 (08/2003)

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