HomeMy WebLinkAboutContract 43751-A1CONTRACT
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FIRST AMENDMENT TO CITY SECRETARY CONTRACT NO. 43751
WHEREAS the City of Fort Worth ("City") and AIDS Outreach Center, Inc. ("Agency"),
made and entered into City Secretary Contract No. 43751 ("Contract");
WHEREAS, the Contract provides funding to Agency pursuant to a grant received by
City from the United States Department of Housing and Urban Development ("HUD") through
the Housing Opportunities for Persons with AIDS ("HOPWA"), Program;
WHEREAS, HUD published new 2013 income limits which apply to the HOPWA Funds
awarded to Agency by the Contract;
WHEREAS, in order to comply with the new HUD income limits, City desires to replace
Attachment III- Client Data Report and Exhibit F- 2012 HUD Income Limits of the Contract
with the new 2013 income limits;
WHEREAS, in order to utilize the new HOPWA Annual Performance Report, City
desires to replace Exhibit G - Overview Report of the Contract with the new HOPWA Annual
Performance Report;
WHEREAS, in addition, City desires to modify the Insurance and Bonding requirements
in the Contract; and
WHEREAS, it is the mutual desire of City and Agency to amend the Contract to meet
Contract objectives.
NOW, THEREFORE, City and Agency hereby agree to amend the Contract as follows:
I.
a. Section 17 Insurance and Bondin2 of the Contract is hereby deleted
and replaced with the following language to be effective October 1, 2012:
17. Insurance and Bondin2.
Agency will maintain coverage in the form of insurance or bond in the
amount of $612,758.90 to insure against loss from the fraud, theft or dishonesty of
any of Agency's officers, agents, trustees, directors or employees. The proceeds
of such insurance or bond shall be used to reimburse City for any and all loss of
HOPWA Funds occasioned by such misconduct. To effectuate such
reimbursement, such fidelity coverage shall include a rider stating that
reimbursement for any loss or losses shall name the City as a Loss Payee.
Agency shall furnish to Citty4nnadle�y
R
First Amendment to CSC No. 43751
AIDS Outreach Center, Inc. (HOPWA)
CITY SECRETARY
0 u NORTH, TX
but not later than the
RECEIVED MAR 1 8 2013
Effective Date, certificates of insurance as proof that it has secured and paid for
policies of commercial insurance as specified herein. If City has not received
such certificates by the Effective Date, Agency shall be in default of the Contract
and City may, at its option, terminate the Contract.
Such insurance shall cover all insurable risks incident to or in connection
with the execution, performance, attempted performance or nonperformance of
this Contract. Agency shall maintain, or require its general contractor to
maintain, the following coverage and limits thereof:
Commercial General Liability (CGL) Insurance
$500,000 each occurrence
$1,000,000 aggregate limit
Non -Profit Organization Liability or Directors & Officers Liability
$1,000,000 Each Occurrence
$1,000,000 Annual Aggregate Limit
Business Automobile Liability Insurance
$1,000,000 each accident on a combined single -limit basis, or
$250,000 Property Damage
$500,000 Bodily Injury per person per occurrence
$2,000,000 Aggregate
Insurance policy shall be endorsed to cover "Any Auto", defined as autos owned, hired,
and non -owned. Pending availability of the above coverage and at the discretion of
City, the policy shall be the primary responding insurance policy versus a personal
auto insurance policy if or when in the course of Agency's business as contracted
herein.
Workers' Compensation Insurance
Part A: Statutory Limits
Part B• Employer's Liability
$100,000 each accident
$100,000 disease -each employee
$500,000 disease -policy limit
Note: Such insurance shall cover employees performing work on any and all
projects including but not limited to construction, demolition, and rehabilitation.
Developer or its contractors shall maintain coverages, if applicable In the event
the respective contractors do not maintain coverage Developer shall maintain the
coverage on such contractor, if applicable, for each applicable contract.
Additional Requirements
First Amendment to CSC No. 43751
AIDS Outreach Center, Inc (HOPWA)
Such insurance amounts shall be revised upward at City's reasonable option and
no more frequently than once every 12 months, and Agency shall revise such
amounts within 30 days following notice to Contractor of such requirements.
Agency will submit to City documentation that it has obtained insurance coverage
and has executed bonds as required in this Contract prior to payment of any
monies provided hereunder.
Where applicable, insurance policies required herein shall be endorsed to include
City as an additional insured as its interest may appear. Additional insured parties
shall include employees, officers, agents, and volunteers of City.
The Workers' Compensation Insurance policy shall be endorsed to include a
waiver of subrogation, also referred to as a waiver of rights of recovery, in favor
of City.
Any failure on part of City to request certificate(s) of insurance shall not be
construed as a waiver of such requirement or as a waiver of the insurance
requirements themselves.
Insurers of Agency s insurance policies shall be licensed to do business in the
state of Texas by the Department of Insurance or be otherwise eligible and
authorized to do business in the state of Texas. Insurers shall be acceptable to
City insofar as their financial strength and solvency and each such company shall
have a current minimum A.M. Best Key Rating Guide rating of A-: VII or other
equivalent insurance industry standard rating otherwise approved by City.
Deductible limits on insurance policies shall not exceed $5,000 per occurrence
unless otherwise approved by City.
In the event there are any local, federal or other regulatory insurance or bonding
requirements for the Program, and such requirements exceed those specified
herein, the former shall prevail.
Agency shall requir e its contractors to maintain applicable insurance coverages,
limits, and other requirements as those specified herein; and Agency shall require
its contractors to provide Agency with certificate(s) of insurance documenting
such coverage. Also, Agency shall require its contractors to have City and
Agency endorsed as additional insureds (as their interest may appear) on their
respective insurance policies.
Directors and Officers Liability coverage shall be in force and may be provided
on a claims made basis. This coverage may also be referred to as Management
Liability, and shall protect the insured against claims arising out of alleged errors
in judgment, breaches of duty and wrongful acts arising out of their organizational
First Amendment to CSC No. 43751
AIDS Outreach Center, Inc (HOPWA)
duties. Coverage shall protect not only the entity, but all past, present and future
directors, officers, trustees, employees, volunteers and committee members
b. Attachment III attached to the Contract is replaced with the attached
Revised Attachment III Client Data Report to be effective February 1, 2013.
c. Exhibit F - 2012 HUD Income Limits attached to the Contract is
replaced with the attached Exhibit F - 2013 HUD Income Limits to be effective
February 1, 2013.
d Exhibit G — Overview Report attached to the Contract is replaced with
the attached Exhibit G — HOPWA Performance Report to be effective February 1,
2013
II.
All other terms and conditions of the Contract not amended herein remain unaffected and
in full force and effect, are binding on the Parties and are hereby ratified by the Parties.
[SIGNATURES APPEAR ON FOLLOWING PAGE]
First Amendment to CSC No. 43751
AIDS Outreach Center, Inc (HOPWA)
ACCEPTED AND AGREED:
AIDS OUTREACH CENTER, INC.
By.:._c
Shannon Hilgart l)
Executive Director
AT EST:
C
y
M&C C
CITY OF FORT WORTH
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By:
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767 Date: 8/7/2012
First Amendment to CSC No. 43751
AIDS Outreach Center, Inc. (HOPWA)
-
a.
+APPROVED AS TO FORMAND LEGALITY:
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Assistant City Attorney
Fernando Costa,
Assistant City Manager
tittO/a-
OFFICIAL RECORD
i, CITY SECRETARY
i rr.WOKTh,"'"`
REVISED ATTACHMENT Ili
CLIENT DATA REPORT
Agency:
Program:
Month:
ThIS report Is meant tolist all Unduplicated clients served during the contract year (October 1, 2012 to September 30, 201 Each month, ease add any new, previously unreported clients, You will also attach eligibility documentation for each new client. New unduplicated
Instructions: dlonts should be listed below previously reported ones, so that this sheet will net as a rolling tally. Please only llst clients one time, dudng the first month that they receive service. Even If a client continues to receive service for multiple months, they only need to be listed one
time. Put an "X, In each appropriate box regarding the client's sex, ethnicity, race, etc
Name
1
2 I
3 I
4 I
5 I
6 I
7
8
9
10
11
12
13
14
15
16
17
18 I
19 I
20 I
21 I
22 I
23
24
25
26
27
28
29
30
31
32
33
34 I
35 I
36 I
37 I
38 I
39
40
41
42
43
44
45
46
47
48
) Undue Ctts for CURRENT MONTH'
L CUMUTATIVE Unduplicated Clients) 1
"Proposed Client Goal Per Contract) 1
% of Mlle Stone MotJ I
'Do not revise the client goal unless the contract Is
amended, accordingly.
Street Address
Sex Ethnicity
(Indicate One) (Indicate One)
Age
Male
Female
Non-
Hlooanic Hinaank
American
Indian or
Alaskan
Native
Native
Hawaiian
Blank or or Other
African Pacific
Asian Amorloan Islander
Race (indicate One)
American
Indian or
American Alaska Other
Indian or Block or Native and Multiple.
Alaskan African Blacker Race
Native and Asian and American African Combinatl
White White White and White American ores'
Disabled
(Indicate One)
Yes
NH Income FHOH
(Doty choose 1 of the 4 columns) (Indicate One)
<30%AMI 31.50% 51430% >80%AMI
AMI AMI
HH Sin 1413850 14323050 14536900 1,836900
24515800 24526.35O124542.150 2>543.150
No 34$17,800 34529,650134547,400 3>547,400
44319750 44332,900144552,650 4>553E50
54821.350 54535550 54556.900 5>556.900
64522,950 64838.200 64$61.100 6>561.100
74524.500 74540,800 74565,300 7,565,300
84326100 84543450 84369.500 8>569.500
Yes No
Amended Exhibit F — 2013 HUD Income Limits
2013 Median Family Income — Fort Worth/Arlington, TX
1 Person 2 Persons 3 Persons 4 Persons 5 Persons 6 Persons 7 Persons 8 Persons
30%AMI $13,850 $15,800 $17,800 $19,750 $21,350 $22,950 $24,500 $26,100
50% AMI $23,050 $26,350 $29,650 $32,900 $35,550 $38,200 $40,800 $43,450
80% AMI $36,900 $42,150 $47,400 $52,650 $56,900 $61,100 $65,300 $69,500
Exhibit "G"
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* 1111110
111111 01
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Housing Opportunities for Persons with AIDS
(HOPWA) Program
Consolidated Annual Performance and
Evaluation Report (CAPER)
Measuring Performance Outcomes
Final Released 1/12/12
OMB Number 2506-0133 (Expiration Date: 10/31/2014)
The CAPER report for HOPWA formula grantees provides annual information on program accomplishments
that supports program evaluation and the ability to measure program beneficiary outcomes as related to:
maintain housing stability prevent homelessness; and improve access to care and support. This information is
also covered under the Consolidated Plan Management Process (CPMP) report and includes Narrative
Responses and Performance Charts required under the Consolidated Planning regulations The public reporting
burden for the collection of information is estimated to average 42 hours per manual response, or less if an
automated data collection and retrieval system is in use, along with 60 hours for record keeping including the
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. Grantees are required to report on the activities
undertaken only, thus there may be components of these reporting requirements that may not be applicable. This
agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless
that collection displays a valid OMB control number.
Previous editions are obsolete form HUD-40110-D (Expiration Date: 10/31/2014)
Overview. The Consolidated Annual Performance and Evaluation Report
(CAPER) provides annual performance reporting on client outputs and
outcomes that enables an assessment of grantee performance in achieving the
housing stability outcome measure. The CAPER, in conjunction with the
Integrated Disbursement Information System (IDIS), fulfills statutory and
regulatory program reporting requirements and provides the grantee and
HUD with the necessary information to assess the overall program
performance and accomplishments against planned goals and objectives.
HOPWA formula grantees are required to submit a CAPER, and complete
annual performance information for all activities undertaken during each
program year in the IDIS, demonstrating coordination with other
Consolidated Plan resources. HUD uses the CAPER and IDIS data to obtain
essential information on grant activities, project sponsors, Subrecipient
organizations, housing sites, units and households, and beneficiaries (which
includes racial and ethnic data on program participants). The Consolidated
Plan Management Process tool (CPMP) provides an optional tool to integrate
the reporting of HOPWA specific activities with other planning and reporting
on Consolidated Plan activities.
Table of Contents
PART 1: Grantee Executive Summary
1. Grantee Information
2. Project Sponsor Information
3. Administrative Subrecipient Information
4. Program Subrecipient Information
5. Grantee Narrative and Performance Assessment
a. Grantee and Community Overview
b. Annual Performance under the Action Plan
c. Barriers or Trends Overview
d. Assessment of Unmet Housing Needs
PART 2: Sources of Leveraging and Program Income
1. Sources of Leveraging
2. Program Income and Resident Rent Payments
PART 3: Accomplishment Data: Planned Goals and Actual Outputs
PART 4: Summary of Performance Outcomes
1. Housing Stability: Permanent Housing and Related Facilities
2. Prevention of Homelessness: Short -Term Housing Payments
3. Access to Care and Support: Housing Subsidy Assistance with
Supportive Services
PART 5: Worksheet - Determining Housing Stability Outcomes
PART 6: Annual Certification of Continued Use for HOPWA Facility -
Based Stewardshin Units (Only)
PART 7: Summary Overview of Grant Activities
A. Information on Individuals, Beneficiaries and Households Receiving
HOPWA Housing Subsidy Assistance (TBRA, STRMU, PHP,Facility
Based Units, Master Leased Units ONLY)
B. Facility -Based Housing Assistance
Continued Use Periods. Grantees that received HOPWA funding for new
construction, acquisition, or substantial rehabilitations are required to operate
their facilities for HOPWA-eligible beneficiaries for a ten (10) years period.
If no further HOPWA finds are used to support the facility, in place of
completing Section 7B of the CAPER, the grantee must submit an Annual
Certification of Continued Project Operation throughout the required use
periods This certification is included in Part 6 in CAPER. The required use
period is three (3) years if the rehabilitation is non -substantial.
hr connection with the development of the Department's standards for
Homeless Management Infonnation Systems (HMIS), universal data
elements are being collected for clients of HOPWA-funded homeless
assistance nroiects. These project sponsor/subrecipient records would
include: Name, Social Security Number, Date of Birth, Ethnicity and Race,
Gender, Veteran Status, Disabling Conditions, Residence Prior to Program
Entry, Zip Code of Last Pennanent Address, Housing Status, Program Entry
Date, Program Exit Date, Personal Identification Number, and Household
Identification Number. These are intended to match the elements under
HMIS. The HOPWA program -level data elements include: Income and
Sources, Non -Cash Benefits, HIV/AIDS Status, Services Provided, and
Housing Status or Destination at the end of the operating year. Other
suggested but optional elements are: Physical Disability, Developmental
Disability, Chronic Health Condition, Mental Health, Substance Abuse,
Domestic Violence, Date of Contact, Date of Engagement, Financial
Previous editions are obsolete Page i
Assistance, Housing Relocation & Stabilization Services, Employment,
Education, General Health Status, , Pregnancy Status, Reasons for Leaving,
Veteran's Information, and Children's Education. Other HOPWA projects
sponsors may also benefit from collecting these data elements.
Final Assembly of Report. After the entire report is assembled, please
number each page sequentially.
Filing Requirements. Within 90 days of the completion of each program
year, grantees must submit their completed CAPER to the CPD Director in
the grantee's State or Local HUD Field Office, and to the HOPWA Program
Office: at HOPWA(a?hud.eov. Electronic submission to HOPWA Program
office is preferred; however, if electronic submission is not possible, hard
copies can be mailed to: Office of HIV/AIDS Housing, Room 7212, U.S.
Department of Housing and Urban Development, 451 Seventh Street, SW,
Washington, D.C.
Record Keeping. Names and other individual infonnation must be kept
confidential, as required by 24 CFR 574.440. However, HUD reserves the
right to review the information used to complete this report for grants
management oversight purposes, except for recording any names and other
identifying information. In the case that HUD must review client level
data, no client names or identifying information will be retained or
recorded. Information is reported in aggregate to HUD without
personal identification. Do not submit client or personal information in
data systems to HUD.
Definitions
Adjustment for Duplication: Enables the calculation of unduplicated
output totals by accounting for the total number of households or units that
received more than one type of HOPWA assistance in a given service
category such as HOPWA Subsidy Assistance or Supportive Services. For
example, if a client household received both TBRA and STRMU during the
operating year, report that household in the category of HOPWA Housing
Subsidy Assistance in Part 3, Chart 1, Column [lb] in the following manner:
HOPWA Housing Subsidy
Assistance
Tenant -Based Rental Assistance
Permanent Housing Facilities:
2a. Received Operating
Subsidies/Leased units
Transitional/Short-term Facilities*
2b. Received Operating Subsidies
3a.
3b.
4.
5.
6.
Permanent Housing Facilities:
Capital Development Projects placed
in service during the operating year
Transitional/Short-term Facilities:
Capital Development Projects placed
in service during the operating year
Short-term Rent, Mortgage, and
Utility Assistance
Adjustment for duplication
(subtract)
TOTAL Housing Subsidy
Assistance (Sum of Rows 1-4 minus
Row 5)
[1] Outputs:
Number of
Households
1
form HUD-40110-D (Expiration Date: 10/31/2014)
Administrative Costs: Costs for general management, oversight,
coordination, evaluation, and reporting. By statute, grantee administrative
costs are limited to 3% of total grant award, to be expended over the life of
the grant. Project sponsor administrative costs are limited to 7% of the
portion of the grant amount they receive.
Beneficiary(ies): All members of a household who received HOPWA
assistance during the operating year including the one individual who
qualified the household for HOPWA assistance as well as any other
members of the household (with or without HIV) who benefitted from the
assistance.
Central Contractor Registration (CCR): The primary registrant
database for the U.S. Federal Government. CCR collects, validates, stores,
and disseminates data in support of agency acquisition missions, including
Federal agency contract and assistance awards. Both current and potential
federal government registrants (grantees) are required to register in CCR
in order to be awarded contracts by the federal government. Registrants
must update or renew their registration at least once per year to maintain
an active status. Although recipients of direct federal contracts and grant
awards have been required to be registered with CCR since 2003, this
requirement is now being extended to indirect recipients of federal funds
with the passage of ARRA (American Recovery and Reinvestment Act).
Per ARRA and FFATA (Federal Funding Accountability and
Transparency Act) federal regulations, all grantees and sub -grantees or
subcontractors receiving federal grant awards or contracts must have a
DUNS (Data Universal Numbering System) Number.
Chronically Homeless Person: An individual or family who : (i) is
homeless and lives or resides individual or family who: (i) Is homeless and
lives or resides in a place not meant for human habitation, a safe haven, or
in an emergency shelter; (ii) has been homeless and living or residing in a
place not meant for human habitation, a safe haven, or in an emergency
shelter continuously for at least 1 year or on at least 4 separate occasions in
the last 3 years; and (iii) has an adult head of household (or a minor head
of household if no adult is present in the household) with a diagnosable
substance use disorder, serious mental illness, developmental disability (as
defined in section 102 of the Developmental Disabilities Assistance and
Bill of Rights Act of 2000 (42 U.S.C. 15002)), post traumatic stress
disorder, cognitive impairments resulting from a brain injury, or chronic
physical illness or disability, including the co -occurrence of 2 or more of
those conditions. Additionally, the statutory definition includes as
chronically homeless a person who currently lives or resides in an
institutional care facility, including a jail, substance abuse or mental health
treatment facility, hospital or other similar facility, and has resided there
for fewer than 90 days if such person met the other criteria for homeless
prior to entering that facility. (See 42 U.S.C. 11360(2))This does not
include doubled -up or overcrowding situations.
Disabling Condition: Evidencing a diagnosable substance use disorder,
serious mental illness, developmental disability, chronic physical illness,
or disability, including the co -occurrence of two or more of these
conditions. In addition, a disabling condition may limit an individual's
ability to work or perform one or more activities of daily living. An
HIV/AIDS diagnosis is considered a disabling condition.
Facility -Based Housing Assistance: All eligible HOPWA Housing
expenditures for or associated with supporting facilities including
community residences, SRO dwellings, short-term facilities, project -based
rental units, master leased units, and other housing facilities approved by
HUD.
Faith -Based Organization: Religious organizations of three types: (1)
congregations; (2) national networks, which include national
denominations, their social service arms (for example, Catholic Charities,
Lutheran Social Services), and networks of related organizations (such as
YMCA and YWCA); and (3) freestanding religious organizations, which
are incorporated separately from congregations and national networks.
Grassroots Organization: An organization headquartered in the local
community where it provides services; has a social services budget of
$300,000 or less annually, and six or fewer fill -time equivalent
employees. Local affiliates of national organizations are not considered
Previous editions are obsolete Page ii
"grassroots."
HOPWA Eligible Individual: The one (1) low-income person with
HIV/AIDS who qualifies a household for HOPWA assistance. This person
may be considered "Head of Household." When the CAPER asks for
information on eligible individuals, report on this individual person only.
Where there is more than one person with HIV/AIDS in the household, the
additional PWH/A(s), would be considered a beneficiary(s).
HOPWA Housing Information Services: Services dedicated to helping
persons living with HIV/AIDS and their families to identify, locate, and
acquire housing. This may also include fair housing counseling for eligible
persons who may encounter discrimination based on race, color, religion,
sex, age, national origin, familial status, or handicap/disability. .
HOPWA Housing Subsidy Assistance Total: The unduplicated number
of households receiving housing subsidies (TBRA, STRMU, Permanent
Housing Placement services and Master Leasing) and/or residing in units
of facilities dedicated to persons living with HIV/AIDS and their families
and supported with HOPWA funds during the operating year.
Household: A single individual or a family composed of two or more
persons for which household incomes are used to detennine eligibility and
for calculation of the resident rent payment. The tern is used for
collecting data on changes in income, changes in access to services, receipt
of housing information services, and outcomes on achieving housing
stability. Live -In Aides (see definition for Live -In Aide) and non -
beneficiaries (e.g. a shared housing arrangement with a roommate) who
resided in the unit are not reported on in the CAPER.
Housing Stability: The degree to which the HOPWA project assisted
beneficiaries to remain in stable housing during the operating year. See
Part S: Determining Housing Stability Outcomes for definitions of stable
and unstable housing situations.
In -kind Leveraged Resources: These involve additional types of support
provided to assist HOPWA beneficiaries such as volunteer services,
materials, use of equipment and building space. The actual value of the
support can be the contribution of professional services, based on
customary rates for this specialized support, or actual costs contributed
from other leveraged resources. In determining a rate for the contribution
of volunteer time and services, use the rate established in HUD notices,
such as the rate of ten dollars per hour. The value of any donated material,
equipment, building, or lease should be based on the fair market value at
time of donation. Related documentation can be from recent bills of sales,
advertised prices, appraisals, or other information for comparable property
similarly situated.
Leveraged Funds: The amount of finds expended during the operating
year from non-HOPWA federal, state, local, and private sources by
grantees or sponsors in dedicating assistance to this client population.
Leveraged finds or other assistance are used directly in or in support of
HOPWA program delivery.
Live -In Aide: A person who resides with the HOPWA Eligible Individual
and who meets the following criteria: (1) is essential to the care and well-
being of the person; (2) is not obligated for the support of the person; and
(3) would not be living in the unit except to provide the necessary
supportive services. See the Code of Federal Regulations Title 24, Part
5.403 and the HOPWA Grantee Oversight Resource Guide for additional
reference.
Master Leasing: Applies to a nonprofit or public agency that leases units
of housing (scattered -sites or entire buildings) from a landlord, and
subleases the units to homeless or low-income tenants. By assuming the
tenancy burden, the agency facilitates housing of clients who may not be
able to maintain a lease on their own due to poor credit, evictions, or lack
of sufficient income.
Operating Costs: Applies to facility -based housing only, for facilities
that are currently open. Operating costs can include day-to-day housing
form HUD-40110-D (Expiration Date: 10/31/2014)
function and operation costs like utilities, maintenance, equipment,
insurance, security, furnishings, supplies and salary for staff costs directly
related to the housing project but not staff costs for delivering services.
Outcome: The degree to which the HOPWA assisted household has been
enabled to establish or maintain a stable living environment in housing that
is safe, decent, and sanitary, (per the regulations at 24 CFR 574.310(b))
and to reduce the risks of homelessness, and improve access to HIV
treatment and other health care and support.
Output: The number of units of housing or households that receive
HOPWA assistance during the operating year.
Permanent Housing Placement: A supportive housing service that helps
establish the household in the housing unit, including but not limited to
reasonable costs for security deposits not to exceed two months of rent
costs.
Program Income: Gross income directly generated from the use of
HOPWA funds, including repayments. See grant administration
requirements on program income for state and local governments at 24
CFR 85.25, or for non -profits at 24 CFR 84.24.
Project -Based Rental Assistance (PBRA): A rental subsidy program
that is tied to specific facilities or units owned or controlled by a project
sponsor or Subrecipient. Assistance is tied directly to the properties and is
not portable or transferable.
Project Sponsor Organizations: Any nonprofit organization or
governmental housing agency that receives fiords under a contract with the
grantee to provide eligible housing and other support services or
administrative services as defined in 24 CFR 574.300. Project Sponsor
organizations are required to provide performance data on households
served and funds expended. Funding flows to a project sponsor as
follows:
HUD Funding ) Grantee > Project Sponsor
Short -Term Rent, Mortgage, and Utility (STRMU) Assistance: A
time -limited, housing subsidy assistance designed to prevent homelessness
and increase housing stability. Grantees may provide assistance for up to
21 weeks in any 52 week period. The amount of assistance varies per
client depending on funds available, tenant need and program guidelines.
Stewardship Units: Units developed with HOPWA, where HOPWA
funds were used for acquisition, new construction and rehabilitation that
no longer receive operating subsidies from HOPWA. Report information
for the units is subject to the three-year use agreement if rehabilitation is
non -substantial and to the ten-year use agreement if rehabilitation is
substantial.
Previous editions are obsolete Page iii
Subrecipient Organization: Any organization that receives funds from a
project sponsor to provide eligible housing and other support services
and/or administrative services as defined in 24 CFR 574.300. If a
subrecipient organization provides housing and/or other supportive
services directly to clients, the subrecipient organization must provide
performance data on household served and fitnds expended. Funding
flows to subrecipients as follows:
HUD Funding > Grantee > Project Sponsor >Subrecipient
Tenant -Based Rental Assistance (TBRA): 1'BRA is a rental subsidy
program similar to the Housing Choice Voucher program that grantees can
provide to help low-income households access affordable housing. The
1 BRA voucher is not tied to a specific unit, so tenants may move to a
different unit without losing their assistance, subject to individual program
rules. The subsidy amount is detennined in part based on household
income and rental costs associated with the tenant's lease.
Transgender: Transgender is defined as a person who identifies with, or
presents as, a gender that is different from his/her gender at birth.
Veteran: A veteran is someone who has served on active duty in the
Armed Forces of the United States. This does not include inactive military
reserves or the National Guard unless the person was called up to active
duty.
form HUD-40110-D (Expiration Date: 10/31/2014)
Housing Opportunities for Person with AIDS (HOPWA)
Consolidated Annual Performance and Evaluation Report (CAPER)
Measuring Performance Outputs and Outcomes
OMB Number 2506-0133 (Expiration Date: 10/31/2014)
'Part 1: Grantee Executive Summary
As applicable, complete the charts below to provide more detailed information about the agencies and organizations responsible
for the administration and implementation of the HOPWA program. Chart 1 requests general Grantee Information and Chart 2 is
to be completed for each organization selected or designated as a project sponsor, as defined by CFR 574 3 In Chart 3, indicate
each subrecipient organization with a contract/agreement of $25,000 or greater that assists grantees or project sponsors carrying
out their administrative or evaluation activities. In Chart 4, indicate each subrecipient organization with a contr act/agreement to
provide HOPWA-funded services to client households. These elements address requirements in the Federal Funding and
Accountability and Transparency Act of 2006 (Public Law 109-282).
Note: Please see the definition section for distinctions between project sponsor and subrecipient.
Note: If any information does not apply t0 your organization, please enter N/A. Do not leave any section blank.
1. Grantee Information
HUD Grant Number
Grantee Name
Business Address
City, County, State, Zip
Employer Identification Number (BIN) or
Tax identification Number (TIN)
DUN & Bradstreet Number (DUNS):
* Congressional District of Grantee's Business
Address
*Congressional District of Primary Service
Area(s)
* City(ies) and County(ies) of Primary Service Cities:
Area(s)
Organization s Website Address
Operating Year for this report
From (ilmddd' j) To (nrn/dt059
Central Contractor Registration (CCR):
Is the grantee's CCR status currently active?
❑ Yes ❑ No
If yes, provide CCR Number:
Counties:
Is there a waiting list(s) for HOPWA Housing Subsidy Assistance
Services in the Grantee service Area? ❑ Yes ❑ No
If yes, explain in the narrative section what services maintain a waiting
List and how this list is administered.
* Service delivery area information only needed for program activities being directly carried out by the grantee.
Previous editions are obsolete
Page 1
form HUD-40110-D (Expiration Date: 10/31/2014)
2. Project Sponsor Information
Please complete Chart 2 for each organization designated or selected to serve as a project sponsor, as defined by CFR 574.3.
Use this section to report on organizations involved in the direct delivery of services for client households These elements
address requirements in the Federal Financial Accountability and Transparency Act of 2006 (Public Law 109-282).
Note: Please see the definitions for distinctions between project sponsor and subrecipient.
Note: If any information does not apply to your organization, please enter N/A.
Project Sponsor Agency Name
Name and Title of Contact at Project
Sponsor Agency
Email Address
Business Address
City, County, State, Zip,
Phone Number (with area code)
Employer Identification Number (EIN) or
Tax Identification Number (TIN)
DUN & Bradstreet Number (DUNs):
Congressional District of Project Sponsor's
Business Address
Congressional District(s) of Primary Service
Area(s)
City(ies) and County(ies) of Primary Service
Area(s)
Total HOPWA contract amount for this
Organization for the operating year
Organization's Website Address
Cities:
Is the sponsor a nonprofit organization? U Yes LI No
Please check ifyes and a faith -based organization.
Please check ifyes and a grassroots organization.
■
■
Parent Company Name, if applicable
Fax Number (with area code)
Counties:
Does your organization maintain a waiting list? U Yes U No
If yes, explain in the narrative section how this list is administered.
Previous editions are obsolete Page 2 form HUD-40110-D (Expiration Date: 10/31/2014)
3. Administrative Subrecipient Information
Use Chart 3 to provide the following information for each subrecipient with a contract/agreement of $25,000 or greater that
assists project sponsors to carry out their administrative services but no services directly to client households. Agreements
include: grants, subgrants, loans, awards, cooperative agreements, and other forms of financial assistance; and contracts,
subcontracts, purchase orders, task orders, and delivery orders. (Organizations listed may have contracts with project sponsors)
These elements address requirements in the Federal Funding and Accountability and Transparency Act of 2006 (Public Law 109-
282).
Note: Please see the definitions for distinctions between project sponsor and subrecipient.
Note: If any infornratioan does not apply to your organization, please enter N/A.
Subrecipient Name
Name and Title of Contact at Subrecipient
Email Address
Business Address
City, State, Zip, County
Phone Number (with area code)
Employer Identification Number (EIN) or
Tax Identification Number (TIN)
DUN & Bradstreet Number (DUNs):
North American Industry Classification
System (NAICS) Code
Congressional District of Subrecipient's
Business Address
Congressional District of Primary Service
Area
City (ies) and County (ies) of Primary Service
Area(s)
Total HOPR A Subcontract Amount of this
Organization for the operating year
Parent Company Name, if applicable
Fax Number (include area code)
Cities: Counties:
Previous editions are obsolete Page 3 form HUD-40110-D (Expiration Date: 10/31/2014)
4. Program Subrecipient Information
Complete the following information for each subrecipient organization providing HOPWA-funded services to client households.
These organizations would hold a contract/agreement with a project sponsor(s) to provide these set vices. For example, a
subrecipient organization may receive funds from a project sponsor to provide nutritional services for clients residing within a
HOPWA facility -based housing program. Please note that subrecipients who work directly with client households must provide
performance data for the grantee to include in Parts 2-7 of the CAPER.
Note: Please see the definition of a subrecipient for more information.
Note: Types of contracts/agreements may include: grants, sub -grants, loans, awards, cooperative agreements, and other forms
of financial assistance; and contracts, subcontracts, purchase orders, task orders, and delivery orders.
Note: If any it formation is not applicable to the organization, please report N/A in the appropriate box. Do not leave boxes
blank.
Sub -recipient Name
Name and Title of Contact at Contractor/
Sub -contractor Agency
Email Address
Business Address
City, County, State, Zip
Phone Number (included area code)
Employer Identification Number (EIN) or
Tax Identification Number (TIN)
DUN & Bradstreet Number (DUNs)
North American Industry Classification
System (NAICS) Code
Congressional District of the Sub -recipient's
Business Address
Congressional District(s) of Primary Service
Area
City(ies) and County(ies) of Primary Service
Area
Total HOPWA Subcontract Amount of this
Organization for the operating year
Cities:
Parent Company Name, if applicable
Fax Number (include area code)
Counties:
Previous editions are obsolete Page 4 form HUD-40110-D (Expiration Date: 10/31/2014)
5. Grantee Narrative and Performance Assessment
a. Grantee and Community Overview
Provide a one to three page narrative summarizing major achievements and highlights that were proposed and completed during
the program year Include a brief description of the grant oiganization, area of service, the name(s) of the program contact(s),
and an overview of the range/type of housing activities provided. This overview may be used for public information, including
posting on HUD's website. Note: Teyt fields are expandable.
b. Annual Performance under the Action Plan
Provide a narrative addressing each of the following four items:
1. Outputs Reported. Describe significant accomplishments or challenges in achieving the number of housing units supported
and the number households assisted with HOPWA funds during this operating year compared to plans for this assistance as
approved in the Consolidated Plan/Action Plan. Describe how HOPWA funds were distributed during your program year among
different categories of housing and geographic areas to address needs throughout the grant service area, consistent with approved
plans.
2. Outcomes Assessed. Assess your program's success in enabling HOPWA beneficiaries to establish and/or better maintain a
stable living environment in housing that is safe, decent, and sanitary and improve access to care. Compare current year results
to baseline results for clients Describe how program activities/projects contributed to meeting stated goals. If program did not
achieve expected targets, please describe how your program plans to address challenges in program implementation and the steps
currently being taken to achieve goals in next operating year. If your program exceeded program targets, please describe
strategies the program utilized and how those contributed to program successes.
3. Coordination. Report on program coordination with other mainstream housing and supportive services resources, including
the use of committed leveraging from other public and private sources that helped to address needs for eligible persons identified
in the Consolidated Plan/Strategic Plan.
4. Technical Assistance. Describe any program technical assistance needs and how they would benefit program beneficiaries.
c. Barriers and Trends Overview
Provide a nari ative addressing items 1 through 3. Explain how barriers and trends affected your program's ability to achieve the
objectives and outcomes discussed in the previous section.
1. Describe any barriers (including regulatory and non -regulatory) encountered in the administration or implementation of
the HOPWA program, how they affected your program's ability to achieve the objectives and outcomes discussed, and,
actions taken in response to barriers, and recommendations foi program improvement. Provide an explanation for each
barrier selected.
❑ HOPWA/HUD Regulations ■ Planning ❑ Housing Availability ❑ Rent Determination and Fair Market
Rents
0 Discrimination/Confidentiality ❑ Multiple Diagnoses ❑ Eligibility ❑ Technical Assistance or Training
❑ Supportive Services ❑ Credit History ❑ Rental History ■ Criminal Justice History
❑ Housing Affordability
❑ Geography/Rural Access D Other, please explain further
Previous editions are obsolete Page 5 form HUD-40110-D (Expiration Date: 10/31/2014)
2. Describe any trends in the community that may affect the way in which the needs of persons living with HIV/AIDS
are being addressed, and provide any other information important to the future provision of services to this population.
3. Identify any evaluations, studies, or other assessments of the HOPWA program that are available to the public.
d. Unmet Housing Needs: An Assessment of Unmet Housing Needs
In Chart 1, provide an assessment of the number of HOPWA-eligible households that require HOPWA housing subsidy
assistance but are not currently served by any HOPWA-funded housing subsidy assistance in this service area.
In Row 1, report the total unmet need of the geographical service area as reported in Unmet Needs for Persons with HI V/AIDS,
Chart 1B of the Consolidated or Annual Plan(s) or as reported under HOPWA worksheet in the Needs Workbook of the
Consolidated Planning Management Process (CPMP) tool.
Note: Report most current data available, Mt ough Consolidated or Annual Plan(s), and account for local housing issues, or
changes in HIV/AIDS cases, by using conbitnatio17 of one or more of the sources in Chart 2.
If data is collected on the type of housing that is needed in Rows a. through c., enter the number of HOPWA-eligible households
by type of housing subsidy assistance needed For an approximate breakdown of overall unmet need by type of housing subsidy
assistance refer to the Consolidated or Annual Plan (s), CPMP tool or local distribution of funds. Do not include clients who are
already receiving HOPWA-funded housing subsidy assistance.
Refer to Chart 2, and check all sources consulted to calculate unmet need. Reference any data from neighboring states' or
municipalities' Consolidated Plan or other planning efforts that informed the assessment of Unmet Need in your service area.
Note: In order to ensure that the unmet need assessment Pt the region is comprehensive, HOPWA formula grantees should
include those unmet needs assessed by HOPWA competitive grantees operating within the service at ea.
1 Planning Estimate of Area's Unmet Needs for HOPWA-Eligible Households
1. Total number of households that have unmet
housing subsidy assistance need.
2. From the total reported in Row 1, identify the
number of households with unmet housing needs
by type of housing subsidy assistance:
a. Tenant -Based Rental Assistance (TBRA)
b. Short -Term Rent, Mortgage and Utility payments
(STRMU)
• Assistance with rental costs
• Assistance with mortgage payments
• Assistance with utility costs.
c. Housing Facilities such as community residences,
SRO dwellings, other housing facilities
Previous editions are obsolete Page 6 form HUD-40110-D (Expiration Date: 10/31/2014)
2. Recommended Data Sources for Assessing Unmet Need (check all sources used)
X = Data as reported in the area Consolidated Plan, e.g. Table 1B, CPMP charts, and related nai ratives
= Data established by area HIV/AIDS housing planning and coordination efforts, e.g. Continuum of Care
= Data from client information provided in Homeless Management Information Systems (HMIS)
= Data from project sponsors or housing providers, including waiting lists for assistance or other assessments on need including those
completed by HOPWA competitive grantees operating in the region.
= Data from prisons or jails on persons being discharged with HIV/AIDS, if mandatory testing is conducted
= Data from local Ryan White Planning Councils or reported in CARE Act Data Reports, e.g. number of clients with permanent
housing
= Data collected for HIV/AIDS surveillance reporting or other health assessments, e.g. local health depai went or CDC surveillance data
End of PART 1
Previous editions are obsolete Page 7 form HUD-40110-D (Expiration Date: 10/31/2014)
IP-ART 2: Sources of Leveraging and Program Income
1. Sources of Leveraging
Report the source(s) of cash or in -kind leveraged federal, state, local or private resources identified in the Consolidated or
Annual Plan and used in the delivery of the HOPWA program and the amount of leveraged dollars. In Column [1], identify the
type of leveraging. Some common sources of leveraged funds have been provided as a reference point. You may add Rows as
necessary to report all sources of leveraged funds. Include Resident Rent payments paid by clients directly to private landlords.
Do NOT include rents paid directly to a HOPWA program as this will be reported in the next section. In Column [2] report the
amount of leveraged funds expended during the operating yeas Use Column [3] to piovide some detail about the type of
leveraged contribution (e g., case management services or clothing donations). In Column [4], check the appropriate box to
indicate whethei the leveraged contribution was a housing subsidy assistance or another form of support.
Note: Be sure to report on the number of households supported with these leveraged fiends in Part 3, Chart 1, Column d
A. Source of Leveraging Chart
[1] Source of Leveraging
Public Funding
Ryan White -Housing Assistance
Ryan White -Other
Housing Choice Voucher Program
Low Income Housing Tax Credit
HOME
Shelter Plus Care
Emergency Solutions Grant
Other Public:
Other Public:
Other Public:
Other Public:
Other Public:
Private Funding
Grants
In -kind Resources
Other Private:
Other Private:
Other Funding
Grantee/Project Sponsor/Subrecipient (Agency) Cash
Resident Rent Payments by Client to Private Landlord
TOTAL (Sum of all Rows)
[2] Amount
of Level aged
Funds
[3] Type of
Contribution
[4] Housing Subsidy
Assistance or Other Support
■
■
■
■
■
■
■
■
Housing Subsidy Assistance
Other Support
Housing Subsidy Assistance
Other Support
Housing Subsidy Assistance
Other Support
Housing Subsidy Assistance
Other Support
Housing Subsidy Assistance
Other Support
Housing Subsidy Assistance
Other Support
Housing Subsidy Assistance
Other Support
Housing Subsidy Assistance
❑Other Support
❑ Housing Subsidy Assistance
❑Other Support
Housing Subsidy Assistance
Other Support
Housing Subsidy Assistance
❑Other Support
n Housing Subsidy Assistance
DOther Support
■
■
■
Housing Subsidy Assistance
❑Other Support
■
Housing Subsidy Assistance
❑ Other Support
Housing Subsidy Assistance
Other Support
Housing Subsidy Assistance
Other Support
■
■
■
Housing Subsidy Assistance
Other Support
Previous editions are obsolete Page 8 form HUD-40110-D (Expiration Date: 10/31/2014)
2. Program Income and Resident Rent Payments
In Section 2, Chart A., report the total amount of program income and resident rent payments directly generated from the use of
HOPWA funds, including repayments. Include resident rent payments collected or paid directly to the HOPWA program. Do
NOT include payments made directly from a client household to a private landlord.
Note: Please see report directions section for definition of program income. (Additional information on program income is
available i» the HOPWA Grantee Oversight Resource Guide).
A. Total Amount Program Income and Resident Rent Payment Collected During the Operating Year
Program Income and Resident Rent Payments Collected
1. Program income (e.g. repayments)
2. Resident Rent Payments made directly to HOPWA Program
3. Total Program Income and Resident Rent Payments (Sum of Rows 1 and 2)
Total Amount of
Program Income
(for this operating
year)
B. Program Income and Resident Rent Payments Expended To Assist HOPWA Households
In Chart B, report on the total program income and resident rent payments (as reported above in Chart A) expended during the
operating year. Use Row 1 to report Program Income and Resident Rent Payments expended on Housing Subsidy Assistance
Programs (i.e., TBRA STRMU, PHP, Master Leased Units and Facility -Based Housing). Use Row 2 to report on the Program
Income and Resident Rent Payment expended on Supportive Services and other non -direct Housing Costs.
Program Income and Resident Rent Payment Expended on
HOPWA programs
Program Income and Resident Rent Payment Expended on Housing Subsidy Assistance costs
2. Program Income and Resident Rent Payment Expended on Supportive Services and other non -
direct housing costs
3. Total Program Income Expended (Sum of Rows 1 and 2)
End of PART 2
Total Amount of Program
Income Expended
(for this operating year)
Previous editions are obsolete Page 9 form HUD-40110-D (Expiration Date: 10/31/2014)
IPART 3: Accomplishment Data Planned Goal and Actual Outputs
In Chart 1, enter performance information (goals and actual outputs) for all activities undertaken during the operating year
supported with HOPWA fiends. Performance is measured by the number of households and units of housing that were supported
with HOPWA or other federal, state, local, or private funds foi the purposes of providing housing assistance and support to
persons living with HIV/AIDS and their families.
Note: The total households assisted with HOPWA fiends and reported in PART 3 of the CAPER should be the same as reported
in the annual year-end IDIS data, and goals reported should be consistent with the Annual Plan information. Any discrepancies
or deviations should be explained in the narrative section of PART 1.
1. HOPWA Performance Planned Goal and Actual Outputs
HOPWA Performance
Planned Goal
and Actual
HOPWA Housing Subsidy Assistance
1. ITenant-Based Rental Assistance
a.!Permanent Housing Facilities:
Received Operating Subsidies/Leased units (Households Served)
2b. Transitional/Sliort-term Facilities:
Received Operating Subsidies/Leased units (Households Served)
(Households Served)
3a. Permanent Housing Facilities:
Capital Development Projects placed in service during the operating year
(Households Served)
3b. ransitional/Sliort-term Facilities:
Capital Development Projects placed in service during the operating year
(Households Served)
14. Short -Tenn Rent, Mortgage and Utility Assistance
5. ('Permanent Housing Placement Services
1. Adjustments for duplication (subtract)
7. Total HOPWA Housing Subsidy Assistance
(Columns a. — d. equal the sum of Rows 1-5 minus Row 6; Columns e. and f. equal
the sum of Rows 1-5)
Housing Development (Construction and Stewardship of facility based housing)
8.
19.
Facility -based units;
Capital Development Projects not yet opened (Housing Units)
Stewardship Units subject to 3 or 10 year use agreements
10. ITotal Housing Developed
(Sum of Rows 78 & 9)
Supportive Services
1 la. Supportive Services provided by project sponsors/subrecipient that also delivered
HOPWA housing subsidy assistance
1 lb Supportive Services provided by project sponsors/subrecipient that only provided
supportive services.
12. Adjustment for duplication (subtract)
13. Total Supportive Services
(Columns a. — d. equal the sum of Rows 11 a. & b. minus Row 12; Columns e. and 1.
equal the sum of Rows lea. & 11b.)
Housing Information Services
14. Housing Information Services
15.'Total Housing Information Services
Previous editions are obsolete Page 10
1
I
[1] Output: Households 12] Output: Funding
HOPWA
Assistance
b.
Leveraged
Households
HOPWA Funds
d.
Q
111 Output: Households
Ill Output: Hous'ngUnits
111 OutputEouseho ds
J11 Output Households
a. o
121 Output: Funding
121 Output: Funding
121 Output: Funding
[2J Output: Funding
form HUD-40110-D (Expiration Date: 10/31/2014)
Grant Administration and Other Activities
16. Resource Identification to establish, coordinate and develop housing assistance resources
17. ethnical Assistance
(if approved in grant agreement)
18. Grantee Administration
(maximum 3% of total HOPWA grant)
19. Project Sponsor Administration
(maximum 7% of portion of HOPWA grant awarded)
)0. Total Grant Administration and Other Activities
(Sum of Rows 16 —19)
Total Expended
21. (Total Expenditures for program year (Sum of Rows 7,10, 13, 15, and 20)
[1] Output Households
i•i i•il. i
welenweell
MI 011011•
ItNI ■law Sri_■ �_■_ri_IMOIt
~M_.■r■_■S■■■
Siam • i .r■'e■'■'
+ t + + + t + + 11 t + t + t
.4:+ti+ ++ t+ + wet oar nr a++t++ ¢
r++.+4+++++.++.+.+++
[2] Output: Funding
[2] Outputs: HOPWA Funds
Expended
Budget Actual
2. Listing of Supportive Services
Report on the households served and use of HOPWA funds for all supportive services. Do NOT report on supportive services
leveraged with non-HOPWA funds.
Data check: Total unduplicated households and expenditures reported in Rotir 17 equal totals reported in Part 3, Chart 1, Row 13.
Supportive Services
1. Adult day care and personal assistance
2. Alcohol and drug abuse services
3. Case management
4. Child care and other child services
5. Education
6. Employment assistance and training
Health/medical/intensive care services, if approved
7. Note: Client records must conform with 24 CFR §574.310
8. Legal services
9. Life skills management (outside of case management)
10. Meals/nutritional services
11. Mental health services
12. Outreach
13. Transportation
Other Activity (if approved in grant agreement).
14. Specify:
Sub -Total Households receiving Supportive Services
15. (Sum of Rows 1-14)
16. Adjustment for Duplication (subtract)
17.
TOTAL Unduplicated Households receiving
Supportive Services (Column [1] equals Row 15
minus Row 16; Column [2] equals sum of Rows 1-14)
Previous editions are obsolete
Page 11
[1] Output: Number of Households
[2] Output: Amount of HOPWA Funds
Expended
form HUD-40110-D (Expiration Date: 10/31/2014)
3. Short -Term Rent, Mortgage and Utility Assistance (STRMU) Summary
In Row a., enter the total number of households served and the amount of HOPWA funds expended on Short -Term Rent,
Mortgage and Utility (STRMU) Assistance. In Row b., enter the total number of STRMU-assisted households that received
assistance with mortgage costs only (no utility costs) and the amount expended assisting these households. In Row c., enter the
total number of STRMU-assisted households that received assistance with both mortgage and utility costs and the amount
expended assisting these households. In Row d., enter the total number of STRMU-assisted households that t eceived assistance
with rental costs only (no utility costs) and the amount expended assisting these households. In Row e., enter the total number of
STRMU-assisted households that received assistance with both rental and utility costs and the amount expended assisting these
households. In Row f., enter the total number of STRMU-assisted households that received assistance with utility costs only (not
Including rent or mortgage costs) and the amount expended assisting these households. In row g., report the amount of STRMU
funds expended to support direct program costs such as program operation staff.
Data Check: The total households reported as served with STRMU in Row a., column [1] and the total amount of HOPIVA fiords reported as
expended in Row a., column [2] equals the household and expenditure total reported for STRMU in Part 3, Chart 1, Roue 4, Cohrmns b. andf.,
respectively.
Data Check: The total number of households reported in Column [1], Rows b., c., d, e., and f. equal the total number of STRAW households
reported in Column [1], Row a. The total amount reported as expended in Column [2], Rows b., c., d., e., f, and g. equal the total amount of
STRMU expenditures reported in Colman [2], Row a.
Housing Subsidy Assistance Categories (STRMU)
Total Short-term mortgage, rent and/or utility (STRMU)
assistance
Of the total STRMU reported on Row a, total who received
b• assistance with mortgage costs ONLY.
Of the total STRMU reported on Row a. total who received
C. assistance with mortgage and utility costs.
d
f.
Of the total STRMU reported on Row a total who received
assistance with rental costs ONLY.
Of the total STRMU reported on Row a total who received
assistance with rental and utility costs.
Of the total STRMU renorted on Row a total who received
assistance with utility costs ONLY.
Direct program delivery costs (e.g., program operations staff
time)
[1] Output Number of
Households Served
End of PART 3
Previous editions are obsolete Page 12
[2] Output: Total
HOPWA Funds Expended
on STRMU during
Operating Year
form HUD-40110-D (Expiration Date: 10/31/2014)
(Part 4: Summary of Performance Outcomes
In Column [1], report the total number of eligible households that received HOPWA housing subsidy assistance, by type.
In Column [2], enter the number of households that continued to access each type of housing subsidy assistance into next
operating year. In Column [3], report the housing status of all households that exited the program.
Data Check: The sum of Cohn nts [2] (Nttntber of Households Continuing) and [3] (Exited Households) equals the total reported in Column[1].
Note.: Refer to the housing stability codes that appear in Part 5. Worksheet - Determining Housing Stability Outcomes.
Section 1. Housing Stability: Assessment of Client Outcomes on Maintaining Housing Stability (Permanent Housing and
Related Facilities)
A. Permanent lousing Subsidy Assistance
Tenant -Based
Rental
Assistance
Permanent
Supportive
Housing
Facilities/ Units
B. Transitiona
Transitional/
Short -Term
Housing
Facilities/ Units
[1] Output: Total
Number of
Households
Served
Housing Assistanc'
[1] Output: Total
Number of
Households
Served
Previous editions are obsolete
[2] Assessment: Number of
Households that Continued
Receiving HOPWA Housing
Subsidy Assistance into the Next
Operating Year
[2] Assessment: Number of
Households that Continued
Receiving HOPWA Housing
Subsidy Assistance into the Next
Operating Year
Page 13
[3] Assessment: Numbei of
Households that exited this
HOPWA Program; their Housing
Status after Exiting
1 Emergency Shelter/Streets
2 Temporary Housing
3 Private Housing
4 Other HOPWA
5 Other Subsidy
6 Institution
7 Jail/Prison
8 Disconnected/Unknown
9 Death
1 Emergency Shelter/Streets
2 Temporary Housing
3 Private Housing
4 Other HOPWA
5 Other Subsidy
6 Institution
7 Jail/Prison
8 Disconnected/Unknown
9 Death
[3] Assessment: Number of
Households that exited this
HOPWA Program; their
Housing Status after Exiting
1 Emergency Shelter/Streets
2 Temporary Housing
3 Private Housing
4 Other HOP\VA
5 Other Subsidy
6 Institution
7 Jail/Prison
8 Disconnected/unknown
9 Death
[4] HOPWA Client
Outcomes
Unstable Arrangements
Temporarily Stable, with Reduced
Risk of Homelessness
Stable/Permanent Housing (PH)
Unstable Arrangements
Life Event
Unstable Arrangements
Temporarily Stable, with Reduced
Risk of Homelessness
Stable/Permanent Housing (PH)
Unstable Arrangements
Life Event
[4] HOPWA Client Outcomes
Unstable Arrangements
Temporarily Stable with Reduced
Risk of Homelessness
Stable/Pet manent Housing (PH)
Unstable Arrangements
Life Event
form HUD-40110-D (Expiration Date: 10/31/2014)
B 1:Total number of households receiving transitional/short-tern housing
assistance whose tenure exceeded 24 months
Section 2. Prevention of Homelessness: Assessment of Client Outcomes on Reduced Risks of Homelessness
(Short -Term Housing Subsidy Assistance)
Report the total number of households that received STRMU assistance in Column [1].
In Column [2] identify the outcomes of the households reported in Column [1] either at the time that they were known to have
left the STRMU program or through the project sponsor or subrecipient's best assessment for stability at the end of the operating
year.
Information in Column [3] provides a description of housing outcomes; therefore, data is not required.
At the bottom of the chart'
• In Row la., report those households that received STRMU assistance during the operating year of this report,
prior operating year.
• In Row lb. report those households that received STRMU assistance during the operating year of this report,
two prior operating years.
Data Check: The total households reported as served with STRMU in Column [1] equals the total reported in Part 3,
Row 4, Column b.
Data Check: The stun of Colunin [2] should equal the number of households reported in Column [1].
Assessment of Households that Received STRMU Assistance
[1] Output: Total [2] Assessment of Housing Status
number of
households
Maintain Private Housing without subsidy
(e.g. Assistance provided/completed and client is stable, not
likely to seek additional support)
Other Private Housing without subsidy
(e.g. client switched housing units and is now stable, not likely
to seek additional support)
Other HOPWA Housing Subsidy Assistance
Other Housing Subsidy (PH)
Institution
(e.g. residential and long-term care)
Likely that additional STRMU is needed to maintain current
housing arrangements
Transitional Facilities/Short-tern
(e.g. temponny or transitional arrangement)
Temporary/Non-Permanent Housing arrangement
(e.g. gave up lease, and moved in with family or friends but
expects to live there less than 90 days)
Emergency Shelter/street
Jail/Prison
Disconnected
Death
and the
and the
Chart 1,
[3] HOPWA Client Outcomes
Stable/Permanent Housing (PH)
PJPuIIM1uIiI iouhWiWV�udiJluhWillnnYVIIIVVIIIIOInIWiu,ii dIIV6ududtl IItlJYiYPa iY11111W61uu YliltluII iIL
Temporarily Stable, with
Reduced Risk of Homelessness
��mwwi�em��wouvommu��mo�mw,umm�o u�W���n�u�daaae����,�oma�����m�1i!I;JJIouaaiW� uni��mmo��uin�au I�Iiaum:
Unstable Arrangements
maeomaiwiaou Wao-omwemuuwuwuuummdu 1111 11 iimPwwoieondda uaaouooBomiom
la Total number of those households that received STRMU Assistance in the operating year of this report tha also received
STRMU assistance in the prior operating year (e.g. households that received STRMU assistance in two consecutive operating
years).
Ib. Total number of those households that received STRMU Assistance in the operating year of this report that also received
STRMU assistance in the two prior operating years (e.g. households that received STRMU assistance in three consecutive
operating years).
Previous editions are obsolete
Page 14
Life Event
form HUD-40110-D (Expiration Date: 10/31/2014)
Section 3. HOPWA Outcomes on Access to Care and Support
la. Total Number of Households
Line [1]: For project sponsors/subrecipients that provided HOPWA housing subsidy assistance during the operating year
identify in the appropi fate row the number of households that received HOPWA housing subsidy assistance (TBRA,
STRMU, Facility -Based, PHP and Master Leasing) and HOPWA funded case management services. Use Row c. to adjust
for duplication among the service categories and Row d. to provide an unduplicated household total.
Line [2]: For project sponsors/subrecipients that did NOT provide HOPWA housing subsidy assistance identify in the
appropriate row the number of households that received HOPWA funded case management services.
Note: These numbers will help you to determine which clients to report Access to Care and Support Outcomes for and will be
used by HUD as a basis for analyzing the pet tentage of households who demonstrated or maintained connections to care and
support as identjed in Chart lb. below.
Total Number of Households
1. For Project Sponsors/Subrecipients that provided HOPWA Housing Subsidy Assistance: Identify the total number of households that
received the following HOPWA-funded services:
a. Housing Subsidy Assistance (duplicated)-IBRA, STRMU, PHP, Facility -Based Housing, and Master Leasing
b. Case Management
Adjustment for duplication (subtraction)
Total Households Served by Project Sponsors/Subrecipients with Housing Subsidy Assistance (Sum of Rows a.b.
c.
d.
minus Row c.)
2. For Project Sponsors/Subrecipients did NOT provide HOPWA Housing Subsidy Assistance:
received the following HOPWA-funded service:
a. HOPWA Case Management
b. Total Households Served by Project Sponsors/Subrecipients without Housing Subsidy Assistance
Identify the total number of households that
lb. Status of Households Accessing Care and Support
Column [1]: Of the households identified as receiving services from project sponsors/subrecipients that provided HOPWA
housing subsidy assistance as identified in Chart la., Row ld. above report the number of households that demonstrated
access or maintained connections to care and support within the program year.
Column [2]: Of the households identified as receiving services from project sponsors/subrecipients that did NOT provide
HOPWA housing subsidy assistance as reported in Chart la., Row 2b., report the number of households that demonstrated
improved access or maintained connections to care and support within the program year.
Note: For information on types and sources of income and medical insurance/assistance, refer to Charts below.
[2] For project
sponsors/subrecipients that
did NOT provide HOPWA Outcome
housing subsidy assistance, Indicator
identify the households who
demonstrated the following:
Categories of Services Accessed
1. Has a housing plan for maintaining or establishing stable on-
going housing
2. Had contact with case manager/benefits counselor consistent
with the schedule specified in client's individual service plan
(may include leveraged services such as Ryan White Medical
Case Management)
3. Had contact with a primary health care provider consistent
with the schedule specified in client's individual service plan
. Accessed and maintained medical insurance/assistance
5. Successfully accessed or maintained qualification for sources
of income
Previous editions are obsolete
[1] For project
sponsors/subrecipients that
provided HOPWA housing subsidy
assistance, identify the households
who demonstrated the following:
Page 15
Support for
Stable
Housing
Access to
Support
Access to
Health Care
Access to
Health Care
Sources of
Income
form HUD-40110-D (Expiration Date: 10/31/2014)
Chart lb., Line 4: Sources of Medical
(Reference only)
• MEDICAID Health Insurance Program, or
use local program
name
• MEDICARE Health Insurance Program, or
use local program name
Insurance and Assistance include, but are not limited to the following
• Veterans Affairs Medical Services
• AIDS Drug Assistance Program (ADAP)
• State Children's Health Insurance Program
(SCHIP), or use local program name
• Ryan White -funded Medical or Dental
Assistance
Chart lb., Row 5: Sources of Income include, but are not limited to the following (Reference only)
• Earned Income
• Veteran's Pension
• Unemployment Insurance
• Pension from Former Job
• Supplemental Security Income (SSI)
• Child Support
• Social Security Disability Income (SSDI)
• Alimony or other Spousal Support
• Veteran's Disability Payment
• Retirement Income from Social Security
• Worker's Compensation
• General Assistance (GA), or use local
program name
• Private Disability Insurance
• Temporary Assistance for Needy
Families (TANF)
• Other Income Sources
le. Households that Obtained Employment
Column [1]: Of the households identified as receiving services from project sponsors/subrecipients that provided HOPWA
housing subsidy assistance as identified in Chart la., Row ld. above, report on the number of households that include
persons who obtained an income -producing job during the operating year that resulted from HOPWA-funded Job training,
employment assistance, education or related case management/counseling set vices
Column [2]: Of the households identified as receiving services from project sponsors/subrecipients that did NOT provide
HOPWA housing subsidy assistance as reported in Chart la , Row 2b., ieport on the number of households that include
persons who obtained an income -producing job during the opeiating year that resulted from HOPWA-funded Job training,
employment assistance, education or case management/counseling services.
Note: This includes jobs created by this project sponsor/subrecipients or obtained outside this agency.
Note: Do not include jobs that resulted fi om leveraged job training, employment assistance, education or case
management/counseling services.
Categories of Services Accessed
Total number of households that
obtained an income -producing. lob
Previous editions are obsolete
[1 For project sponsors/subrecipients that
provided HOPWA housing subsidy
assistance, identify the households who
demonstrated the following:
End of PART 4
Page 16
[2] For project sponsors/subrecipients that did
NOT provide HOPWA housing subsidy assistance,
identify the households who demonstrated the
following:
form HUD-40110-D (Expiration Date: 10/31/2014)
IPART 5: Worksheet - Determining Housing Stability Outcomes (optional)
1. This chart is designed to assess program results based on the information reported in Part 4 and to help Grantees determine
overall program performance. Completion of this worksheet is optional.
Permanent Stable Housing
Housing Subsidy (# of households
Assistance remaining in program
plus 3+4+5+6)
Tenant -Based
Rental Assistance
(TBRA)
Permanent Facility -
based Housing
Assistance/Units
Transitional/Short-
Term Facility -based
Housing
Assistance/Units
Total Permanent
HOPWA Housing
Subsidy Assistance
Reduced Risk o
f
Homelessness:
Short -Term
Assistance
Short -Term Rent,
Mortgage, and
Utility Assistance
(STRMU)
Total HOPWA
Housing Subsidy
Assistance
......04 ...i,
Stable/Permanent
Housing
Temporary Housing
(2)
Temporarily Stable, with Reduced Risk of
Homelessness
Unstable
Arrangements
(1+7+8)
Unstable
Arrangements
Life Event
(9)
Life Events
Background on HOPWA Housing Stability Codes
Stable Permanent Housing/Ongoing Pai ticipation
3 = Private Housing in the private rental or home ownership market (without known subsidy, including permanent placement
with families or other self-sufficient arrangements) with reasonable expectation that additional support is not needed.
4 = Other HOPWA-funded housing subsidy assistance (not STRMU), e.g TBRA or Facility -Based Assistance.
5 = Other subsidized house or apartment (non-HOPWA sources, e.g. Section 8, HOME, public housing).
6 = Institutional setting with greater support and continued residence expected (e.g., residential or long-term care facility).
Temporary Housing
2 = Temporary housing - moved in with family/friends or other short-term arrangement, such as Ryan White subsidy, transitional
housing for homeless, or tempoiary placement in institution (e.g. hospital, psychiatric hospital or other psychiatric facility,
substance abuse treatment facility or detox center).
Unstable Arrangements
1 = Emergency shelter or no housing destination such as places not meant for habitation (e.g., a vehicle, an abandoned building,
bus/train/subway station, or anywhere outside).
7 = Jail /prison.
8 = Disconnected or disappeared from project support, unknown destination or no assessments of housing needs were
undertaken.
Life Event
9 = Death, i.e., remained in housing until death. This characteristic is not factored into the housing stability equation.
Tenant -based Rental Assistance: Stable Housing is the sum of the number of households that (i) remain in the housing and (ii)
those that left the assistance as reported under: 3, 4, 5, and 6. Temporary Housing is the number of households that accessed
assistance, and left their current housing for a non -permanent housing arrangement, as reported under item. 2. Unstable
Situations is the sum of numbers reported under items. 1, 7, and 8.
Previous editions are obsolete
Page 17 form HUD-40110-D (Expiration Date: 10/31/2014)
1
Permanent Facility -Based Housing Assistance: Stable Housing is the sum of the number of households that (i) remain in the
housing and (ii) those that left the assistance as shown as items: 3, 4, 5, and 6. Temporary Housing is the number of households
that accessed assistance, and left their current housing for a non -permanent housing arrangement, as reported under item 2
Unstable Situations is the sum of numbers reported under items: 1, 7, and 8.
Transitional/Short-Term Facility -Based Housing Assistance: Stable Housing is the sum of the number of households that (i)
continue in the residences (ii) those that left the assistance as shown as items: 3, 4, 5 and 6. Other Temporary Housing is the
number of households that accessed assistance, and left their current housing for a non -permanent housing arrangement, as
reported under item 2. Unstable Situations is the sum of numbers reported under items: 1, 7, and 8.
Tenure Assessment. A baseline of households in transitional/short-term facilities for assessment purposes, indicate the number
of households whose tenure exceeded 24 months.
STRMU Assistance: Stable Housing is the sum of the number of households that accessed assistance for some portion of the
permitted 21-week period and there is reasonable expectation that additional support is not needed in order to maintain
permanent housing living situation (as this is a time -limited foi m of housing support) as reported under housing status: Maintain
Private Housing with subsidy; Other Private with Subsidy; Other HOPWA support; Other Housing Subsidy; and Institution.
Temporarily Stable. with Reduced Risk of Homelessness is the sum of the number of households that accessed assistance for
some portion of the permitted 21-week period or left their current housing arrangement for a transitional facility or other
temporary/non-permanent housing arrangement and there is reasonable expectation additional support will be needed to maintain
housing arrangements in the next year, as reported under housing status: Likely to maintain current housing arrangements, with
additional STRMU assistance; Transitional Facilities/Short-term; and Temporary/Non-Permanent Housing arrangements
Unstable Situation is the sum of number of households reported under housing status: Emergency Shelter; Jail/Prison; and
Disconnected.
Previous editions are obsolete
End of PART 5
Page 18 form HUD-40110-D (Expiration Date: 10/31/2014)
IPART 6: Annual Certification of Continued Usage for HOPWA Facility -Based Stewardship Units (ONLY)
The Annual Certification of Usage for HOPWA Facility -Based Stewardship Units is to be used in place of Part 7B of the
CAPER if the facility was originally acquired, rehabilitated or constructed/developed in part with HOPWA funds but no
HOPWA funds were expended during the operating year. Scattered site units may be grouped together on one page.
Grantees that used HOPWA funding for new construction, acquisition, or substantial rehabilitation are required to
operate their facilities for HOPWA eligible individuals for at least ten (10) years. If non -substantial rehabilitation funds
were used they ate required to operate for at least three (3) years. Stewardship begins once the facility is put into
operation.
Note: See definition of Stewardship Units.
1. General information
HUD Grant Number(s)
Grantee Name
2. Number of Units and Non-HOPWA Expenditures
Facility Name:
Total Stewardship Units
(subject to 3- or 10- year use periods)
3. Details of Project Site
Project Sites: Name of HOPWA-funded project
Site Information: Project Zip Code(s)
Site Information: Congressional District(s)
Is the address of the project site confidential?
If the site is not confidential:
Please provide the contact information, phone,
email address/location, if business address is
different from facility address
Number of Stewardship Units
Developed with HOPWA
funds
Operating Year for this report
Froin (nnn/d&y) To (min/dc165) ❑ Final Yr
❑ Yr 1; ❑ Yr 2; ❑ Yr 3; ■ Yr 4; ❑ Yr 5; ❑ Yr 6;
■
Yr7; ❑Yr8; ❑Yr9; ❑Yr10;
Date Facil ty Began Operations (n mr/dd/7J)
Amount of Non-HOPWA Funds Expended in Support of the
Stewardship Units during the Operating Year
Yes, protect information; do not list
Not confidential; information can be made available to the public
I certify that the facility that received assistance for acquisition, rehabilitation or new construction from the Housing Opportunities
for Persons with AIDS Program has operated as a facility to assist HOPWA-eligible persons from the date shown above. I also
certify that the grant is still serving the planned number of HOPWA-eligible households at this facility through leveraged resources
and all other requirements of the grant agreement are being satisfied.
is hereby certify that all the information stated herein, as well as any rnfonnation provided in the accompaniment herewith, is true and accurate.
.,..
Name & Title of Authorized Official of the organization that continues Signature & Date (mm/dd/yy)
to operate the facility:
Name & Title of Contact at Grantee Agency Contact Phone (with area code)
(person who can answer questions about the report and program)
Previous editions are obsolete
End of PART 6
Page 19 form HUD-40110-D (Expiration Date: 10/31/2014)
Part 7: Summary Overview of Grant Activities
A. Information on Individuals, Beneficiaries, and Households Receiving HOPWA Housing Subsidy Assistance
(TBRA, STRMU, Facility -Based Units, Permanent Housing Placement and Master Leased Units ONLY)
Note: Reporting for this section should include ONLY those individuals, beneficiaries, o, households that received and/or
resided in a household that received HOPIVA Housing Subsidy Assistance as reported in Part 3, Chart 1, Row 7, Column b.
(e.g., do not include households that received HOPWI'A supportive services ONLY).
Section 1. HOPWA-Eligible Individuals who Received HOPWA Housing Subsidy Assistance
a. Total HOPWA Eligible Individuals Living with HIV/AIDS
In Chart a., piovide the total number of eligible (and unduplicated) low-income individuals living with HIV/AIDS who qualified
their household to receive HOPWA housing subsidy assistance during the operating year. This total should include only the
individual who qualified the household for HOPWA assistance, NOT all HIV positive individuals in the household.
Individuals Served with Housing Subsidy Assistance
Number of individuals with HIV/AIDS who qualified their household to receive HOPWA housing subsidy assistance.
Total
Chart b. Prior Living Situation
In Chart b., report the prior living situations for all Eligible Individuals reported in Chart a. In Row 1, report the total number of
individuals who continued to receive HOPWA housing subsidy assistance from the prior operating year into this operating year.
In Rows 2 through 17, indicate the prior living arrangements for all new HOPWA housing subsidy assistance recipients during
the operating year.
Data Check: The total number of eligible individuals sewed in Row 18 equals the total number of individuals served through
housing subsidy assistance reported i11 Chart a. above.
Category
1. I Continuine to receive HOPWA support from the prior operating year
New Individuals who received HOPWA Housing Subsidy Assistance support during Operating Year
2 Place not meant for human habitation
(such as a vehicle, abandoned building, bus/train/subway station/airport, or outside)
3. Emergency shelter (including hotel motel, or campground paid for with emergency shelter voucher)
4.
5.
6.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
Transitional housing for homeless persons
Total number of new Eligible Individuals who received HOPWA Housing Subsidy Assistance with a Prior
Living Situation that meets HUD definition of homelessness (Sum of Rims 2 — 4)
Permanent housing for formerly homeless persons (such as Shelter Plus Care, SHP, or SRO Mod
Rehab)
Psychiatric hospital or other psychiatric facility
Substance abuse treatment facility or detox center
Hospital (non -psychiatric facility)
Foster care home or foster care group home
Jail, prison or juvenile detention facility
Rented room, apartment, or house
House you own
Staying or living in someone else's (family and friends) room, apartment, or house
Hotel or motel paid for without emergency shelter voucher
Other
Don't Know or Refiised
TOTAL Number of HOPWA Eligible Individuals (sum of Rows 1 and 5-17)
Total HOPWA
Eligible Individuals
Receiving Housing
Subsidy Assistance
Previous editions are obsolete Page 20 form HUD-40110-D (Expiration Date: 10/31/2014)
c. Homeless Individual Summary
In Chart c., indicate the number of eligible individuals reported in Chart b., Row 5 as homeless who also are homeless Veterans
and/or meet the definition for Chronically Homeless (See Definition section of CAPER). The totals in Chart c. do not need to
equal the total in Chart b., Row 5.
Category
HOPWA eligible individuals served with
HOPWA Housing Subsidy Assistance
Number of
Homeless
Veteran(s)
Number of Chronically
Homeless
Section 2. Beneficiaries
In Chart a., report the total number of HOPWA eligible individuals living with HIV/AIDS who received HOPWA housing
subsidy assistance (as reported in Part 7A, Section 1 Chat t a.), and all associated members of their household who benefitted
from receiving HOPWA housing subsidy assistance (resided with HOPWA eligible individuals).
Note: See definition of HOPTIA Eligible Individual
Note: See definition of Transgender.
Note: See definition of Beneficiaries.
Data Check: The sum of each of the Charts b. & c. on the following two pages equals the total number of beneficiaries served
with HOPWA housing subsidy assistance as determined in Chart a., Row 4 below.
a. Total Number of Beneficial ies Served with HOPWA Housing Subsidy Assistance
Individuals and Families Served with HOPWA Housing Subsidy Assistance
1. Number of individuals with HIV/AIDS who qualified the household to receive HOPWA housing subsidy
assistance (equals the number of HOPWA Eligible Individuals reported in Part 7A, Section 1 Chart a )
2. Number of ALL other persons diagnosed as HIV positive who reside with the HOPWA eligible individuals
identified in Row 1 and who benefitted from the HOPWA housing subsidy assistance
3 Number of ALL other persons NOT diagnosed as HIV positive who reside with the HOPWA eligible
individual identified in Row 1 and who benefited from the HOPWA housing subsidy
4. TOTAL number of ALL beneficiaries served with Housing Subsidy Assistance (Sum of Rows 1,2, & 3)
Total Number
Previous editions are obsolete Page 21 form HUD-40110-D (Expiration Date: 10/31/2014)
b. Age and Gender
In Chart b., indicate the Age and Gender of all beneficiaries as reported in Chart a. directly above. Report the Age and Gender of
all HOPWA Eligible Individuals (those reported in Chart a., Row 1) using Rows 1-5 below and the Age and Gender of all other
beneficiaries (those reported in Chart a., Rows 2 and 3) using Rows 6-10 below. The number of individuals reported in Row 11,
Column E. equals the total number of beneficiaries reported in Part 7, Section 2, Chart a., Row 4.
1. Under 18
2. 18 to 30 years
3. 31 to 50 years
51 years and
4. Older
Subtotal (Sum
5. of Rows 1-4)
Under 18
18 to 30 years
8. 31 to 50 years
51 years and
9. Older
Subtotal (Sum
10. of Rows 6-9)
11.
TOTAL (Sum
of Rows 5 & 10)
HOPWA Eligible Individuals (Chart a, Row 1)
A. B.
Male Female
C.
Transgender Al to F
D. E.
TOTAL (Sum of
Transgcnder F to M Columns A-D)
All Other Beneficiaries (Chart a, Rows 2 and 3)
A. B. C. D. E
Male
TOTAL (Sum of
Female Transgender M to F Transgender F to M Columns A-D)
Total Beneficiaries (Chart a, Row 4)
Previous editions are obsolete Page 22 form HUD-40110-D (Expiration Date: 10/31/2014)
c. Race and Ethnicity*
In Chart c., indicate the Race and Ethnicity of all beneficiaries receiving HOPWA Housing Subsidy Assistance as reported in
Section 2, Chart a , Row 4. Report the race of all HOPWA eligible individuals in Column [A] Report the ethnicity of all
HOPWA eligible individuals in column [B]. Report the race of all other individuals who benefitted from the HOPWA housing
subsidy assistance in column [C]. Repo 't the ethnicity of all other individuals who benefitted from the HOPWA housing subsidy
assistance in column [D]. The summed total of columns [A] and [C] equals the total number of beneficiaries reported above in
Section 2, Chart a., Row 4.
1.
2.
5.
7.
8
10.
Category
American Indian/Alaskan Native
Asian
Black/African American
Native Hawaiian/Other Pacific Islander
White
American Indian/Alaskan Native & White
Asian & White
Black/African American & White
American Indian/Alaskan Native &
Black/African American
Other Multi -Racial
Column Totals (Sum of Rows 1-10)
HOPWA Eligible Individuals
[A] Race
[all individuals
reported in
Section 2, Chart
a., Row 1]
[B] Ethnicity
[Also identified as
H spanic or
Latino]
All Other Beneficiaries
IC] Race
[total of
individuals
reported in
Section 2, Chart
a., Rows 2 & 3]
[D] Ethnicity
[Also identified as
H spanic or
Latino]
Data Check: Sum of Roar 11 Column A and Row 11 Column C equals the total nanber HOPIVA Beneficiaries reported in Pai t 3A, Section 2,
Char! a., Row 4.
*Reference (data requested consistent with Form HUD-27061 Race and Ethnic Data Reporting Form)
Section 3. Households
Household Area Median Income
Report the area median income(s) for all households served with HOPWA housing subsidy assistance.
Data Check: The total number of households soiled with HOPWA housing subsidy assistance should equal Part 3C, Row 7,
Column b and Part 7A, Section 1, Chart a. (Total HOPWA Eligible Individuals Served with HOPTT'A Housing Subsidy
Assistance).
Note: Refer to htty://wwwJntduser.org/portal/datasets/il/i12010/select
income in your community.
Percentage of Area Median Income
1. 0-30% of area median income (extremely low)
2. 31-50% of area median income (very low)
3. 51-80% of area median income (low)
4.
Geography mfi. odn for information 011 area median
Total (Sum of Rows 1-3)
Previous editions are obsolete Page 23
Households Served with HOPWA Housing Subsidy
Assistance
form HUD-40110-D (Expiration Date: 10/31/2014)
Part 7: Summary Overview of Grant Activities
B. Facility -Based Housing Assistance
Complete one Part 7B for each facility developed or supported through HOPWA funds.
Do not complete this Section for programs originally developed with HOPWA funds but no longer supported with
HOPWA funds. If a facility was developed with HOPWA funds (subject to ten years of operation for acquisition, new
construction and substantial rehabilitation costs of stewardship units, or three years for non -substantial rehabilitation costs), but
HOPWA finds are no longer used to support the facility, the project sponsor o1 subrecipient should complete Part 6: Annual
Certification of Continued Usage for HOPWA Facility -Based Stewardship Units (ONLY)
Complete Charts 2a., Project Site Information, and 2b., Type of HOPWA Capital Development Project Units, for all
Development Projects, including facilities that were past development projects but continued to receive HOPWA operating
dollars this reporting year.
1. Project Sponsor/Subrecipient Agency Name (Required)
2. Capital Development
2a. Project Site Information for HOPWA Capital Development of Projects (For Current or Past Capital
Development Projects that receive HOPWA Operating Costs this reporting year)
Note: If units are scattered -sites, report 017 them as a gi oup and under type of Facility write "Scattered Sites. "
Type of
Development
this operating
year
■
New construction
Rehabilitation
Acquisition
Operating
HOPWA
Funds
Expended
this operating
year
(if applicable)
$
a. Purchase/lease of property:
b. Rehabilitation/Construction Dates:
c
f.
Operation dates:
Date supportive services began:
Non-HOPWA funds
Expended
(if applicable)
Number of units in the facility:
Is a waiting list maintained for the facility?
What is the address of the facility (if different from business address)?
Is the address of the project site confidential?
Previous editions are obsolete
Page 24
Name of Facility:
Type of Facility [Check only one box.]
Permanent housing
Short -tern Shelter or Transitional housing
Supportive services only facility
■
Date (mm/dd/yy):
Date started:
Date residents began to occupy:
❑ Not yet occupied
Date Completed:
Date started:
❑ Not yet providing services
HOPWA-fimded units = Total Units =
❑ Yes ❑ No
Ifyes, numbe • of participants on the list at the end of operating year
■
■
Yes, protect information; do not publish list
No, can be made available to the public
form HUD-40110-D (Expiration Date: 10/31/2014)
2b. Number and Type of HOPWA Capital Development Project Units (For Current or Past Capital
Development Projects that receive HOPWA Operating Costs this Reporting Year)
For units entered above in 2a. please list the number of HOPWA units that fulfill the following criteria:
Number Designated Number
for the Chronically Designated to Number Energy- Number 504 Accessible
Homeless Assist the Star Compliant
Homeless
Rental units constructed
(new) and/or acquired
with or without rehab
Rental units rehabbed
Homeownership units
constructed (if approved)
3. Units Assisted in Types of Housing Facility/Units Leased by Project Sponsor or Subrecipient
Charts 3a.. 3b. and 4 are rectuired for each facility. In Charts 3a. and 3b., indicate the type and number of housing units in the
facility, including master leased units, project -based or other scattered site units leased by the organization, categorized by the
number of bedrooms per unit.
Note: The number units may not equal the total number of households served.
Please complete separate charts for each housing facility assisted. Scattered site units may be grouped together.
3a. Check one only
❑ Permanent Supportive Housing Facility/Units
❑ Short-term Shelter or Transitional Supportive Housing Facility/Units
3b. Type of Facility
Complete the following Chart for all facilities leased, master leased, project -based, or operated with HOPWA funds during the
reporting year
Name of Project Sponsor/Agency Operating the Facility/Leased Units:
Total Number of Units in use during the Operating Year
Type of housing facility operated by the Categorized by the Number of Bedrooms per Units
project sponsor/subrecipient SRO/Studio/0
bdrm
Single room occupancy dwelling
b. Community residence
Project -based rental assistance units or leased units
Other housing facility
Specify:
1
bdrm
2
bdrm
3
bdrm
4
bdrm
5+bdrm
.
t+<4 4: f+
4 4 4+ 4 4
+ 4...#:.4 + 4..
4 4:4: 4.4
4 4 4 4 4
F.4 4 4.•....
4. Households and Housing Expenditures
Enter the total number of households served and the amount of HOPWA funds expended by the project sponsor/subrecipient on
subsidies for housing involving the use of facilities, master leased units, project based or other scattered site units leased by the
organization.
Housing Assistance Category: Facility Based Housing
a.
b.
c.
d.
e.
f.
Leasing Costs
Operating Costs
Project -Based Rental Assistance (PBRA) or other leased units
Other Activity (if approved in grant agreement) Specify:
Adjustment to eliminate duplication (subtract)
TOTAL Facility -Based Housing Assistance
(Sum Rows a. through d. minus Row e.)
Previous editions are obsolete
Output: Number of
Households
Output Total HOPWA Funds Expended during
Operating Year by Project Sponsor/subrecipient
Page 25 form HUD-40110-D (Expiration Date: 10/31/2014)
M&C Review
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Official site of the City of Fort Worth, Texas
FORT WORTH
COUNCIL ACTION: Approved As Amended on 8/7/2012 - Ordinance No. 20316-08-2012
DATE:
CODE:
SUBJECT:
7/24/2012
C
CONTINUED FROM A PREVIOUS WEEK
REFERENCE
NO..
TYPE:
C-25767
NON -
CONSENT
LOG NAME: 17HUDACTPLANPYI2-13
PUBLIC
HEARING:
YES
Conduct a Public Hearing and Approve City's 2012-2013 Action Plan for the Use of
Federal Grant Funds from the United States Department of Housing and Urban
Development in the Amount of $9,278,851 00 for Program Year 2012-2013 from the
Community Development Block Grant, HOME Investment Partnerships Program,
Emergency Solutions Grant and Housing Opportunities for Persons with AIDS Grant
Programs, Authorize Collection and Use of Program Income Authorize Application of
Indirect Cost Rates, Authorize Execution of Related Contracts and Interdepartmental
Letters of Agreement and Adopt Appropriation Ordinance (ALL COUNCIL DISTRICTS)
RECOMMENDATION:
It is recommended that the City Council:
1. Conduct a public hearing to allow citizen input and consideration of the City's 2012-2013 Action
Plan for use of federal grant funds from the United States Department of Housing and Urban
Development in the amount of $9,278,851.00 for Program Year 2012-2013 from the Community
Development Block Grant, HOME Investment Partnerships Program, Emergency Solutions Grant and
Housing Opportunities for Persons with AIDS grant programs and for the use of program income from
activities using prior years' federal grant funds;
2. Approve the City's 2012-2013 Action Plan for submission to the United States Department of
Housing and Urban Development including allocations of grant funds to particular programs and
activities as detailed below;
3. Authorize the collection and use of an estimated $50,000.00 of program income resulting from
activities using prior years' Community Development Block Grant funds for the programs and
activities detailed below;
4. Authorize the collection and use of any program income resulting from activities using prior years'
HOME Investment Partnerships Program funds for the City's Homebuyer Assistance Program,
5. Authorize the City Manager, or his designee, to execute contracts and interdepartmental Letters of
Agreement for a one year term with the agencies listed below in Tables 1, 2, and 3 for Program Year
2012-2013 for Community Development Block Grant, Emergency Solutions Grant and Housing
Opportunities for Persons with AIDS grant funds, contingent upon receipt of funding;
6. Authorize the City Manager, or his designee, to extend the contracts and interdepartmental Letters
of Agreement for up to one year if an agency or department requests an extension and such
extension is necessary for completion of the program;
7 Authorize the City Manager, or his designee, to amend the contracts and interdepartmental Letters
of Agreement if necessary, to achieve program goals, provided any amendment is within the scope of
the program and in compliance with City policies and all applicable laws and regulations governing
the use of federal grant funds;
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8. Apply indirect cost rates as applicable for the Grants Fund in accordance with the City's
Administrative Regulations; and
9. Adopt the attached appropriation ordinance increasing the estimated receipts and appropriations to
the Grants Fund in the total amount of $9,278,851.00 ($5,830,119.00 in Community Development
Block Grant funds, $1,973,169.00 in HOME Investment Partnerships Program funds $532,857.00 in
Emergency Solutions Grant funds and $942,706.00 in Housing Opportunities for Persons with AIDS
funds) plus any program income all subject to receipt of such funds.
DISCUSSION:
The City's Action Plan is a comprehensive summary of the major housing and community
development activities programs and proposed expenditures for the use of federal grant funds in the
amount of $9,278 851.00 from the United States Department of Housing and Urban Development
(HUD) for the program year beginning October 1, 2012 and ending September 30, 2013 from the
Community Development Block Grant (CDBG), HOME Investment Partnerships Program (HOME),
Emergency Solutions Grant (ESG) and Housing Opportunities for Persons with AIDS (HOPWA) grant
programs. This year's Action Plan also summarizes the use of program income resulting from
activities using prior years' CDBG and HOME funds. The purpose of these grant funds is to primarily
benefit low and moderate income City residents, with ESG funds primarily benefiting homeless
persons and HOPWA funds primarily benefiting persons with HIV/AIDS
A 30-day public comment period on the City's proposed Action Plan was held from June 25, 2012 to
July 25, 2012. Any comments will be maintained by the Housing and Economic Development
Department in accordance with federal regulations. This public hearing on the City's Action Plan will
be the first public hearing for the HUD required citizen participation process A second public hearing
is proposed for August 7, 2012 at which time the City Council is scheduled to approve the Action
Plan. The City's Action Plan must be submitted to HUD by August 16, 2012.
In addition, two public hearings were held on July 16, 2012 at 9:30 a.m. and 6:00 p.m. for citizens to
provide comment on the proposed lists of neighborhood streets eligible for reconstruction using
CDBG funds. The Transportation and Public Works Department prepared a list of priority streets in
CDBG-eligible areas The streets selected for reconstruction were based on the comments provided
at the public hearings A complete list of the streets is attached and will be included in the Action
Plan.
The allocations in the draft Action Plan available during the public comment period were based on
funding estimates available at that time. The amounts set out below reflect the allocations from HUD
at the time of this Mayor and Council Communication (M&C). The allocations are not yet final and if
the amounts increase, Staff will bring forward another M&C to commit the additional funds. Staff
developed recommendations for the allocation of the estimated funding from HUD and presented
them to the Community Development Council (CDC) on June 4 2012 A summary of the CDC's
funding recommendations is provided below in Tables 1, 2 and 3 and a spreadsheet of all specific
funding recommendations is attached
For Program Year 2012-2013, the $5,830,119.00 in CDBG funds and $50,000.00 of CDBG program
income is recommended to be allocated as follows:
Housing Programs and Services - $2,124,038.00
This item includes funding for the City's Priority Repair Program, Cowtown Brush -Up, homebuyer and
housing services, and accessibility modifications to the homes of senior and/or disabled individuals
and related project delivery costs for these programs.
Public Services - $874,517.85
This item includes social services for low to moderate income, disabled, and disadvantaged
populations.
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Community Facilities and Infrastructure - $930,596.05
This item includes funding for neighborhood streets reconstruction and streetlight installation for the
Terrell Heights neighborhood.
CDBG Economic Development - $734,943.30
This item is this year's payment of the City's Section 108 loan from HUD.
CDBG General Administration - $1,166,023.80
This item includes costs for administering the CDBG grant including allocations for Financial
Management Services, Internal Audit, and Planning and Development.
CDBG Estimated Program Income - $50,000.00
Staff recommends allocating any CDBG program received to the following items.
CASA of Tarrant County, Inc. $ 1,875.00
Cultural Arts Center $ 1,875.00
Day Resource Center for the Homeless $ 1,875.00
YWCA Fort Worth & Tarrant County $ 1,875.00
Neighborhood Street
Reconstruction $32,500.00
CDBG General Administration (20 percent) $10,000.00
Total CDBG Program Income $50,000.00
For Program Year 2012-2013, the $1 973,169.00 in HOME funds is recommended to be allocated as
follows:
HOME General Administration - $197,316.90
This item includes costs for administering the HOME grant.
Community Development Housing Organizations (CHDO) Set Aside - $0.00
This HUD required minimum allocation has been met with previous years' awards to CHDOs for
nonprofit affordable housing projects and CHDO administrative operating costs.
Homebuyer Assistance Program - $1,775,852.10
This item includes funding to provide down payment and/or closing cost assistance to low and
moderate income homebuyers.
Staff anticipates the receipt of program income in the 2012-2013 Program Year from activities using
HOME funds. Any future program income will be used for the City s Homebuyer Assistance Program
(HAP) after the 10 percent allocation, excluding recapture, for HOME General Administration.
For Program Year 2012-2013, the $532,857.00 in ESG grant funds is recommended to be allocated
as follows:
Allocation to non-profit service providers - $492,892.72
Allocation to ESG program administration - $39,964.28
For Program Year 2012-2013, the $942,706.00 in HOPWA grant funds is recommended to be
allocated as follows:
Allocation to non-profit service providers - $914,424.82
Allocation to HOPWA program administration - $28,281.18
The CDC and Staff recommend that contracts be executed with the agencies listed below in the
amounts shown in the following tables:
Community Development Block Grant:
Table 1 - CDBG Agencies
Organization Program Amount
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Camp Fire USA First Texas Council
CASA of Tarrant County, Inc.
Cenikor Foundation
Clayton Child Care. Inc. d/b/a Clayton
YES!
Cornerstone Assistance Network
Cultural Arts Center
Day Resource Center for the Homeless
The Ladder Alliance
Mental Health Association of Tarrant
County
Northside Inter -Church Agency, Inc.
Senior Citizen Services of Greater
Tarrant County
Tarrant Area Food Bank
YWCA Fort Worth & Tarrant County
YWCA Fort Worth & Tarrant County
CDBG Public Service Subtotal
REACH Resource Center on
Independent Living
TOTAL CDBG Contracts
Emeraencv Solutions Grant:
Table 2 - ESG Agencies
Organization
Catholic Charities of Fort Worth
CFW: Parks and Community Services
P resbyterian Night Shelter
S afeHaven of Tarrant County
Day Resource Center
Diamond Hill and
N orthside Station
Volunteer Advocate
Training
S ubstance Abuse
Treatment
School Age Child Care
N ew Life Center/Promise
House
GED in Spanish
Counseling Services and
Case Management
Employment Training
Long Term Care
Ombudsman
Good Works/Buenas
O bras
Transportation for
Seniors
Community
Kitchen/Meals
Child Development
Program
Power of Self
Project Ramp
Program
Prevention and Rapid
Re -Housing
Community Action
Partners
The Emergency Shelter
P rogram
S helter Operations and
Rapid Re -Housing
Counseling Services and
Case Management
TOTAL ESG Contracts
Housing Onnortunities For Persons With AIDS:
Table 3 - HOPWA Agencies
Organization
AIDS Outreach Center, Inc.
Tarrant County Samaritan Housing, Inc.
$ 75,900.00
$ 30,000.00
$ 75,000.00
$ 75,000.00
$ 75, 000.00
$ 30,000.00
31,808.50
75,000.00
75,000.85
75,000.00
75,000.00
75,000.00
$ 75,000.00
$ 31.808.50
$ 874,517.85
$ 50.000.00
$ 924,517.85
Amount
$ 38,178.52
$ 75,000.00
$ 167,892.72
$ 175,000.00
$ 36,821.48
492,892.72
Program Amount
Administration (three percent), $ 612,758.90
S upportive Services, TBRA, and
STRMU
Administration (three percent),
S upportive Services, and TBRA
TOTAL HOPWA Contracts
These programs are available in ALL COUNCIL DISTRICTS.
$ 301.665.92
$ 914,424.82
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FISCAL INFORMATION/CERTIFICATION:
The Financial Management Services Director certifies that upon approval of the above
recommendations, adoption of the attached appropriation ordinance and receipt of grant funds, funds
will be available in the current operating budget, as appropriated, of the Grants Fund.
TO Fund/Account/Centers
GR76 451727 017206280XXX
GR76 5XXXXX 017206280XXX
GR76 451727 017206281XXX
GR76 5XXXXX
017206281XXX
GR76 5XXXXX 017206283XXX
GR76 451727 017206284XXX
GR76 5XXXXX 017206284XXX
GR76 451685 017206280XXX
GR76 5XXXXX 017206280XXX
GR76 451727 017206283XXX
$5.830.119.00
$5.830.119.00
$1.973.169.00
$1.973.169.00
$532.857.00
$942.706.00
$942.706.00
$50.000.00
$50.000.00
$532.857.00
Submitted for City Manaaer's Office by:
Oriainatina Department Head:
Additional Information Contact:
FROM Fund/Account/Centers
Fernando Costa (6122)
Jay Chapa (5804)
Cynthia Garcia (8187)
Avis F. Chaisson (6342)
ATTACHMENTS
17HUDACTPLANPY12-13 A012 VG(1).doc
2012-13ActionPlanFundinaRecommendations.odf
List of Selected Streets for 2012-2013.pdf
http://apps.cfwnet.org/council_packet/mc_review.asp?ID=17008&councildate-8/7/2012 11/27/2012