The URL can be used to link to this page

Home My WebLink AboutContract 43742-A1CITYo�rSECRETARYi wnil�l FIRST AMENDMENT TO CITY SECRETARY CONTRACT NO. 43742 WHEREAS the City of Fort Worth ("City") and Tarrant County Samaritan Housing, Inc. ("Agency"), made and entered into City Secretary Contract No. 43742 ("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 Bonding of the Contract is hereby deleted and replaced with the following language to be effective October 1, 2012: 17. Insurance and Bonding. Agency will maintain coverage in the form of insurance or bond in the amount of $301,665.92 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 City in a timely manner, but not later than the First Amendment to CSC No. 43742 Tarrant County Samaritan Housing, Inc. (HOPI RECEIVED MAR 18 2f313 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. 43742 Tarrant County Samaritan Housing, 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 Depth ttuent 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 require 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 m judgment, breaches of duty and wrongful acts arising out of their organizational First Amendment to CSC No. 43742 Tarrant County Samaritan Housing, 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. 43742 Tarrant County Samaritan Housing, Inc. (HOPWA) ACCEPTED AND AGREED: TARRANT COUNTY SAMARITAN HOUSING, INC. No rt Wiiite\, Presi�lent/CEO CITY OF FORT WORTH Vertif By: fri Fernando Costa, f011t),4444 AsCity Manager A's o..O00AOp40 zr( I 7 Date: 8/7/20 °op 00 81114f „ikAPPROVE 0 ocP° siKAY ClaX, °n°��.�,"�''' Assistant City Attorney 81111:050- 4 First Amendment to CSC No. 43742 Tarrant County Samaritan Housing, Inc. (HOPWA) TO FORM AND LEGALITY: OFFICIAL RECORD CITY SECRETARY PtVVORTH,TX ''I 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 REVISED ATTACHMENT III CLIENT DATA REPORT Agency: Program: Month: Instructions: This report is meant to list all unduplicated clients served during the contract year (October 1, 2012 to September 30, 2013). Each month. please add any new, previously unreported clients. You will also attach eligibility documentation for each new client. New unduplicated clients should be listed below previously reported ones, so that 1Ns sheet will ad as a roiling tally. Please only list clients one time, during the first month that they receive service. Even it 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. ceti o Milestone Me J 'Do not revise the client goal unless the contract is amended, accordingly. Name Street Address Age I Sex (indica e One) Maio Female Ethnicity (Indicate One) Hlaoanic Non- Hlaoanlc American Indian or Alaskan Native Aalen Black or African American Native Hcwallan or Other Pacific Islander Race (Indicate One) White American Indian or Alaskan Native and White Asian and White Black or African American and White American Indian or Alaska Other Native and Multiple Black or Roca African Combinatl American ono' Disabled (indicate One) Yea No HH Size HH Income (Only choose 1 of the 4 columns) 40% AMI 11413,850 2415 1 ;i'V"g.750 5421.350 �4 1d.500 8426.100 31-50% AMI 1 < �'`'u 050 240dA.35U 3429.650 4432 Ain, g}5 +,�0 �a4dt�t� <S43.450 1, 51-80% AMI >80% AMI FHOH (Indicate One) 14I.4W Yea 44.. 7.650 f; 7.650 SSb900 re 1 100 !s 5.300 W.500 746S �'t ) 8469.500 gS 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" 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 (IRIS), fulfills statutory and regulatory program reporting requirements and provides the grantee and HUD with the necessary information to assess the overall program perfonnance 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 -Tenn 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 Stewardship 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 funds 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. In connection with the development of the Department's standards for Homeless Management Information Systems (HMIS), universal data elements are being collected for clients of HOPWA-funded homeless assistance projects. These project sponsor/subrecipient records would include: Naive, Social Security Number, Date of Birth, Ethnicity and Race, Gender, Veteran Status, Disabling Conditions, Residence Prior to Program Entry, Zip Code of Last Permanent Address, Housing Status, Program Entry Date, Program Exit Date, Personal Identification Number, and Household Identification Number. These are intended to match the elements under HMIS. The HOPWA program -level data elements include: Income and Sources, Non -Cash Benefits, HIV/AIDS Status, Services Provided, 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 flffire• at 1-1(1PtATAGnlhnri any Flertrnnir ciihmiccinn to Hf1PWA Prnararn 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 information must be kept confidential, as required by 24 CFR 574.440. However, HUD reserves the right to review the information used to complete this report for grants management oversight purposes, except for recording any names and other identifying information. In the case that HUD must review client level data, no client names or identifying information will be retained or recorded. Information is reported in aggregate to HUD without personal identification. Do not submit client or personal information in data systems to HUD. 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 1. 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. 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 -tern Rent, Mortgage, and Utility Assistance Adjustment for duplication (subtract) TOTAL Housing Subsidy 6. Assistance (Sum of Rows 1-4 minus Row 5) [1] Outputs: Number of Households i 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 of2000 (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 anus (for example, Catholic Charities, Lutheran Social Services), and networks of related organizations (such as YMCA and YWCA); and (3) freestanding religious organizations, which are incorporated separately from congregations and national networks. Grassroots Organization: An organization headquartered in the local community where it provides services; has a social services budget of $300,000 or less annually, and six or fewer full-time equivalent employees. Local affiliates of national organizations are not considered Previous editions are obsolete Page 11 "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 term is used for collecting data on changes in income, changes in access to services, receipt of housing information services, and outcomes on achieving housing stability. Live -In Aides (see definition for Live -In Aide) and non - beneficiaries (e.g. a shared housing arrangement with a roommate) who resided in the unit are not reported on in the CAPER. Housing Stability: The degree to which the HOPWA project assisted beneficiaries to remain in stable housing during the operating year. See Part 5: Determining Housing Stability Outcomes for definitions of stable and unstable housing situations. In -kind Leveraged Resources: These 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 funds expended during the operating year from non-HOPWA federal, state, local, and private sources by grantees or sponsors in dedicating assistance to this client population. Leveraged funds or other assistance are used directly in or in support of HOPWA program delivery. Live -In Aide: A person who resides with the HOPWA Eligible Individual and who meets the following criteria: (1) is essential to the care and well- being of the person; (2) is not obligated for the support of the person; and (3) would not be living in the unit except to provide the necessary supportive services. See the Code of Federal Regulations Title 24, Part 5.403 and the HOPIVA 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 govemments 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 funds under a contract with the grantee to provide eligible housing and other support services or administrative services as defined in 24 CFR 574.300. Project Sponsor organizations are required to provide performance data on households served and funds expended. 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 funds expended. Funding flows to subrecipients as follows: HUD Funding > Grantee > Project Sponsor >Subrecipient Tenant -Based Rental Assistance (TBRA): TBRA is a rental subsidy program similar to the Housing Choice Voucher program that grantees can provide to help low-income households access affordable housing. The TBRA voucher is not tied to a specific unit, so tenants may move to a different unit without losing their assistance, subject to individual program rules. The subsidy amount is determined in part based on household income and rental costs associated with the tenant's lease. Transgender: Transgender is defined as a person who identifies with, or presents as, a gender that is different from 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 oiganizations 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 contract/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 to 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 (EIN) 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 Area(s) Organization s Website Address Cities: 1 Operating Year for this report From (nnn/dd/17) To (min/dd411) Central Contractor Registration (CCR): Is the grantee's CCR status currently active? Yes ❑ No If yes, provide CCR Number: ■ ICounties: 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 foi 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? LJ Yes U No Please check ifyes and a faith -based organization. Please check ifyes and a grassroots organization. ■ 0 Parent Company Name, if applicable Fax Number (with area code) Counties: Does your organization maintain a waiting list? ■ Yes ❑ 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 to 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 information 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 HOPWA Subcontract Amount of this Organization for the operating year s^:.:..-. Parent Company Name, if applicable Fax Number (include area code) ICounties: 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 services. 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 offinancial assistance; and contracts, subcontracts, purchase orders, task orders, and delivery orders. Note: If any information 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 organization, area of service, the name(s) of the program contact(s), and an overview of the range/type of housing activities provided This overview may be used for public information, including posting on HUD's website. Note: Text fields are expandable. b. Annual Performance under the Action Plan Provide a narrative addressing each of the following four items: 1. Outputs Reported. Describe significant accomplishments or challenges in achieving the number of housing units supported and the number households assisted with HOPWA funds during this operating year compared to plans for this assistance as approved in the Consolidated Plan/Action Plan. Describe how HOPWA funds were distributed during your 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 narrative addressing items 1 through 3. Explain how barriers and trends affected your program's ability to achieve the objectives and outcomes discussed in the previous section 1. Describe any barriers (including regulatory and non -regulatory) encountered in the administration or implementation of the HOPWA program, how they affected your program's ability to achieve the objectives and outcomes discussed, and, actions taken in response to barriers, and recommendations for program improvement. Provide an explanation for each barrier selected. ❑ HOPWA/1-IUD Regulations Discrimination/Confidentiality Supportive Services Housing Affordability ■ ■ Planning ❑ Multiple Diagnoses ❑ Credit History ■ Geography/Rural Access ] Housing Availability ❑ Eligibility ❑ Rental History ■ Other, please explain further ❑ Rent Determination and Fair Market Rents ❑ Technical Assistance or Training Criminal Justice History 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 HIV/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, through Consolidated or Annual Plan(s), and account for local housing issues, or changes in HIV/AIDS cases, by using combination 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 for the region is comprehensive, HOPWA formula grantees should include those unmet needs assessed by HOPWA competitive grantees operating within the service area. 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 narratives = 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 department or CDC surveillance data End of PART 1 Previous editions are obsolete Page 7 form HUD-40110-D (Expiration Date: 10/31/2014) PART 2: Sources of Leveraging and Program Income 1. Sources of Leveraging Report the source(s) of cash or in -kind leveraged federal, state, local or private resources identified in the Consolidated or Annual Plan and used in the delivery of the HOPWA program and the amount of leveraged dollars. In Column [1], identify the type of leveraging. Some common sources of leveraged funds have been provided as a reference point. You may add Rows as necessary to report all sources of leveraged funds Include Resident Rent payments paid by clients directly to private landlords. Do NOT include rents paid directly to a HOPWA program as this will be reported in the next section. In Column [2] report the amount of leveraged funds expended during the operating year Use Column [3] to provide some detail about the type of leveraged contribution (e g., case management services or clothing donations) In Column [4], check the appropriate box to indicate whether the leveraged contribution was a housing subsidy assistance or another form of support. Note: Be sure to report on the number of households supported with these leveraged funds in Part 3, Chart 1, Column d. A. Source of Leveraging Chart [1] Source of Leveraging 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 Leveraged [3] Type of [4] Housing Subsidy Funds Contribution Assistance or Other Support [Mousing 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 [Mousing 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 [Mousing Subsidy Assistance ['Other Support ❑Housing Subsidy Assistance ['Other Support Housing Subsidy Assistance Other Su•.ort 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 011 program income is available in the HOPWA Grantee Oversight Resource Guide). A. Total Amount Program Income and Resident Rent Payment Collected During the Operating Year Program Income and Resident Rent Payments Collected 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 1. Program Income and Resident Rent Payment Expended on Housing Subsidy Assistance costs 2. Program Income and Resident Rent Payment Expended on Supportive Services and other non - direct housing costs 3. Total Program Income Expended (Sum of Rows 1 and 2) End of PART 2 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) 14, PART 3: Accomplishment Data Planned Goal and Actual Outputs In Chart 1, enter performance information (goals and actual outputs) for all activities undertaken during the operating year supported with HOPWA funds. Performance is measured by the number of households and units of housing that were supported with HOPWA or other federal, state, local, or private funds for the purposes of providing housing assistance and support to persons living with HIV/AIDS and their families. Note: The total households assisted with HOPWA finds and reported in PART 3 of the CAPER should be the sane as reported in the annual year-end IRIS 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 IIHOPWA Housing Subsidy Assistance 11. EenantBaseRental Assistance a. Permanent Housing Facilities: eceived Operating Subsidies/Leased units (Households Served) b. Transitional/Short-term Facilities: Received Operating Subsidies/Leased units (Households Served) (Households Served) 3a. IPermanent Housing Facilities: apital Development Projects placed in service during the operating year (Households Served) 3b. TransitionaUShort-term Facilities: Capital Development Projects placed in service during the operating year (Households Served) Short -Tenn Rent, Mortgage and Utility Assistance I5. Permanent Housing Placement Services 16. [Adjustments for duplication (subtract) F7. otal 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) Facility -based units; Capital Development Projects not yet opened (Housing Units) Stewardship Units subject to 3 or 10 year use agreements Total Housing Developed SSum of Rows 78 & 9) Supportive Services 11 a. Supportive Services provided by project sponsors/subrecipient that also delivered HOPWA housing subsidy assistance 11 b Supportive Services provided by project sponsors/subrecipient that only provided 1. 'supportive services. J12. (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 f. equal the sum of Rows l la. & l lb.) Housing Information Services 14. 'Housing Information Services 15. otal Housing Information Services Previous editions are obsolete Page 10 • [1] Output: Households [2] Output: Funding HOPWA Leveraged Assistance Households a. b. c. d. HOPWA Funds e. f. a xd 111 Output: Households [2] Output: Funding [11 Output: Housing Units I [2] Output: Funding ['] Output Households [ l] Output Households [2] Output: Funding [2] Output: Funding form HUD-40110-D (Expiration Date: 10/31/2014) i J Grant Administration and Other Activities 16. Resource Identification to establish, coordinate and develop housing assistance resources 17. Technical Assistance (if approved in grant agreement) 18. Grantee Administration (maximum 3% of total HOPWA grant) 19. Project Sponsor Administration (maximum 7% of portion of HOPWA grant awarded) 20. Total Grant Administration and Other Activities (Sum of Rows 16 — 19) Total Expended 121, Total Expenditures for program year (Sum of Rows 7, 10, 13, 15, and 20) [1] Output Households ■ • • • iil ■ i ■ ■ ■ ■ • •_u 11 s • 11 •_■_ • ■_•_u■ • 111, • •sta■iii.■'•••• s ■■■■■■■■■■■■■■ i i i 'i ■ 1 '• II ■'•■•• i i • iii i i I • ■ 1• i • • i iii liii I•■• • •1• • • a iii l• • • iii■ •■ •iii ■ ■ ■ 11 ■ ■ 11 ■ ■ ■ ■ ■ ■ ■ oS +*4+4f+4.ai'+44 •f + f f f++ • f f f f f f f fff4494'..++++++4 4 tff IF4• • [2] Output: Funding [2] Outputs: HOPWA Funds Exp nded 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 Row 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. I Education 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. Employment assistance and training Health/medical/intensive care services, if approved Note: Client records must conform with 24 CFR §574.310 Legal services Life skills management (outside of case management) Meals/nutritional services Mental health services Outreach Transportation Other Activity (if approved in grant agreement). Specify: Sub -Total Households receiving Supportive Services (Sum of Rows 1-14) Adjustment for Duplication (subtract) TOTAL Unduplicated Households receiving Supportive Services (Column [1] equals Row 15 minus Row 16; Column [2] equals sum of Rows 1-14) [1] Output: Number of Households Previous editions are obsolete Page 11 [2] Output: Amount of HOPWA Funds Expended ■f■■■■■■ ■ ■ ■ 1 ■■■■■■■ ■■■■■■■■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ 1 ..5555555. 45555555." • • form HUD-40110-D (Expiration Date: 10/31/2014) i i 3. Short -Term Rent, Mortgage and Utihty Assistance (STRMU) Summary In Row a., enter the total number of households served and the amount of HOPWA funds expended on Short -Term Rent, Mortgage and Utility (STRMU) Assistance. In Row b., enter the total number of STRMU-assisted households that received assistance with mortgage costs only (no utility costs) and the amount expended assisting these households. In Row c., enter the total number of STRMU-assisted households that received assistance with both mortgage and utility costs and the amount expended assisting these households. In Row d., enter the total number of STRMU-assisted households that received assistance with rental costs only (no utility costs) and the amount expended assisting these households In Row e , enter the total number of STRMU-assisted households that received assistance with both rental and utility costs and the amount expended assisting these households. In Row f., enter the total number of STRMU-assisted households that received assistance with utility costs only (not including rent or mortgage costs) and the amount expended assisting these households. In i ow 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 HOPTVA f ads reported as expended in Row a., column [2] equals the household and expenditure total reported for STRMU in Part 3, Chart 1, Row 4, Columns b. and f., respectively. Data Check: The total number of households reported in Column [I], Rows b., c., d., e., and f. equal the total number of STRMU households reported in Cohnnn [1], Row a. The total amount reported as expended in Column [2], Rows b., c., d., e., f, and g. equal the total amount of STRMU expenditures reported in Column [2], Row a. Housing Subsidy Assistance Categories (STRMU) Total Short-term mortgage, rent and/or utility (STRMU) a• 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. Of the total STRMU reported on Row a total who received d• assistance with rental costs ONLY. e. f. g• Of the total STRMU reported on Row a. total who received assistance with rental and utility costs. Of the total STRMU reported 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 star of Cohn ins [2] (Number of Households Contiuing) 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 3ous►ng 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 Assistance [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: 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 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 HOPWA 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/Permanent Housing (PH) Unstable Arrangements Life Event form HUD-40110-D (Expiration Date: 10/31/2014) B 1:Total number of households receiving transitional/short-term housing assistance whose tenure exceeded 24 months Section 2. Prevention of Homelessness: Assessment of Client Outcomes on Reduced Risks of Homelessness (Short -Term Housing Subsidy Assistance) Report the total number of households that received STRMU assistance in Column [1]. In Column [2], identify the outcomes of the households reported in Column [1] either at the time that they were known to have Left the STRMU program or through the project sponsor 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 1 a., 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 Coltann [1] equals the total reported in Part 3, Row 4, Column b. Data Check: The sum of Column [2] should equal the number of households reported in Column [1]. Assessment of Households that Received STRMU Assistance [1] Output: Total number of households [2] Assessment of Housing Status 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-term (e.g. temporary or transitional arrangement) Temporary/Non-Permanent Housing arrangement (e.g. gave up lease, and moved in with family o _r lends 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) Temporarily Stable, with Reduced Risk of Homelessness mix I HI i Imi li lu 11111111111 uoluoe uluWwl lu uli 11 uuowItlil1J I Unstable Arrangements udll 11' 1 tli iululami mlllllllltli 1 111111, lVitldli Illllllld it Iduualil lilull Life Event I a. 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). I b. 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 form HUD-401 10-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 ident fy in the appropriate tow 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 identified 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)-TBRA, STRMU, PHP, Facility -Based Housing, and Master Leasing b. Case Management c. Adjustment for duplication (subtraction) d. Total Households Served by Project Sponsors/Subrecipients with Housing Subsidy Assistance (Sum of Rows a.b. minus Row c.) 2. For Project Sponsors/Subrecipients did NOT provide HOPWA Housing Subsidy Assistance: Identify the total number of households that received the following HOPWA-funded service: a. HOPWA Case Management b. Total Households Served by Project Sponsors/Subrecipients without Housing Subsidy Assistance 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 1 a., Row 1 d. 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 1 a., 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 4. Accessed and maintained mnedicalinsurance/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 Insurance and Assistance include, but are not limited to the following (Reference only) • MEDICAID Health Insurance Program, or • Veterans Affairs Medical Services use local program • AIDS Drug Assistance Program (ADAP) name • State Children's Health Insurance Program • MEDICARE Health Insurance Program, or (SCHIP), or use local program name use local vrogram name Chart lb., Row 5: Sources of Income in • Earned Income • Veteran's Pension • Unemployment Insurance • Pension from Former Job • Supplemental Security Income (SSI) elude, but are not Limited to the • Child Support • Social Security Disability Income (SSDI) • Alimony or other Spousal Support • Veteran's Disability Payment • Retirement Income from Social Security • Worker's Compensation • Ryan White -funded Medical or Dental Assistance following (Reference only) • 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 services Column [2]: Of the households identified as receiving services from project sponsors/subrecipients that did NOT provide HOPWA housing subsidy assistance as reported to Chart l a., Row 2b., report on the number of households that include persons who obtained an income -producing job during the operating year that resulted from HOPWA-funded Job training, employment assistance, education or case management/counseling services. Note: This includes jobs created by this project sponsor/subrecipients or obtained outside this agency. Note: Do not include jobs that resulted from leveraged job training, employment assistance, education or case management/counseling services. Categories of Services Accessed Total number of households that obtained an income -producing job 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 pi ogram 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 Temporary Housing Unstable Life Event Housing Subsidy (# of households (2) Arrangements (9) Assistance remaining in program (1+7+8) plus 3+4+5+6) Tenant -Based Rental Assistance (TBRA) Permanent Facility - based Housing Assistance/Units Transitional/Short- Tenn Facility -based Housing Assistance/Units Total Permanent HOPWA Housing Subsidy Assistance Reduced Risk of Homelessness: Short -Term Assistance Short -Tern Rent, Mortgage, and Utility Assistance (STRMU) Total HOPWA Housing Subsidy Assistance Housing Pr Homelessness Arrangements Background on HOPWA Housing Stability Codes Stable Permanent Housing/Ongoing Participation 3 = Private Housing in the private rental or home ownership market (without known subsidy, including permanent placement with families or other self-sufficient arrangements) with reasonable expectation that additional support is not needed. 4 = Other HOPWA-funded housing subsidy assistance (not STRMU), e.g. TBRA or Facility -Based Assistance. 5 = Other subsidized house or apartment (non-HOPWA sources, e.g., Section 8, HOME, public housing). 6 = Institutional setting with greater support and continued residence expected (e.g., residential or long-term care facility). Temporary Housing 2 = Temporary housing - moved in with family/friends or other short-term arrangement, such as Ryan White subsidy, transitional housing for homeless, or temporary placement in institution (e.g. hospital, psychiatric hospital or other psychiatric facility, substance abuse treatment facility or detox center). Unstable Arrangements 1 = Emergency shelter or no housing destination such as places not meant for habitation (e.g., a vehicle, an abandoned building, bus/train/subway station, or anywhere outside). 7 = Jail /prison. 8 = Disconnected or disappeared from project support, unknown destination or no assessments of housing needs were undertaken. Life Event 9 = Death, i.e., remained in housing until death. This characteristic is not factored into the housing stability equation. Tenant -based Rental Assistance: Stable Housing is the sum of the number of households that (i) remain in the housing and (ii) those that left the assistance as reported under: 3, 4, 5, and 6. Temnorary 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 form of housing support) as reported under housing status: Maintain Private Housing with subsidy; Other Private with Subsidy; Other HOPWA support; Other Housing Subsidy; and Institution. Temporarily Stable. with Reduced Risk of Homelessness is the sum of the number of households that accessed assistance for some portion of the permitted 21-week period or left their current housing arrangement for a transitional facility or other temporary/non-permanent housing arrangement and there is reasonable expectation additional support will be needed to maintain housing arrangements in the next year, as reported under housing status: Likely to maintain current housing arrangements, with additional STRMU assistance; Transitional Facilities/Short-term; and Temporary/Non-Permanent Housing arrangements Unstable Situation is the sum of number of households reported under housing status: Emergency Shelter; Jail/Prison; and Disconnected. Previous editions are obsolete End of PART 5 Page 18 form HUD-40110-D (Expiration Date: 10/31/2014) PART 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 aie 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) Number of Stewardship Units Developed with HOPWA funds Operating Year for this report From (nnn/dd/yy) To (n m/dd/yy) ❑ Final Yr ❑ Yr 1; ❑ Yr 2; ❑ Yr 3; ❑ Yr 4; ❑ Yr 5; ❑ Yr 6; ❑ Yr 7; ❑ Yr 8; ❑ Yr 9; ❑ Yr 10; Date Facility Began Operations (n m/dd/i}) Amount of Non-HOPWA Funds Expended in Support of the Qtnrvortichin Unite rl..rina the. flnnrotin.r vnor 3. Details of Project Site Project Sites: Name of HOPWA-funded project Site Information: Project Zip Code(s) Site Information: Congressional District(s) Is the address of the project site confidential? ❑ Yes, protect information; do not list ❑ Not confidential; information can be made available to the public If the site is not confidential: Please provide the contact information, phone, email address/location, if business address is different from facility address 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 facihty through leveraged resources and all other requirements of the grant agreement are being satisfied. r I hereby certify that all the information stated herein, as well as any information 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 HOPWA Housing Subsidy Assistance as reported in Part 3, Chart 1, Row 7, Column b. (e.g., do not include households that received HOPWA supportive services ONLY). Section 1. HOPWA-Eligible Individuals who Received HOPWA Housing Subsidy Assistance a. Total HOPWA Eligible Individuals Living with HIV/AIDS In Chart a., provide the total number of eligible (and unduplicated) low-income individuals living with HIV/AIDS who qualified their household to receive HOPWA housing subsidy assistance during the operating year. This total should include only the individual who qualified the household for HOPWA assistance, NOT all HIV positive individuals in the household. Individuals Served with Housing Subsidy Assistance 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 served in Row 18 equals the total number of individuals served through housing subsidy assistance reported in Chart a. above. Category 1. Continuing to receive HOPWA support from the pnor operating year New Individuals who received HOPWA Housing Subsidy Assistance support during Operating Year 2 Place not meant for human habitation (such as a vehicle, abandoned building, bus/train/subway station/airport, or outside) 3. Emergency shelter (including hotel, motel, or campground paid for with emergency shelter voucher) 4. Transitional housing for homeless persons 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. Total number of new Eligible Individuals who received HOPWA Housing Subsidy Assistance with a Prior Living Situation that meets HUD definition of homelessness (Sum of Rows 2 — 4) 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-psychiatnc facility) Foster care home or foster care group home Jail, prison or Juvenile detention facihty Rented room, apai lucent, or house House you own Staying or living in someone else's (family and fnends) room, apartment, or house Hotel or motel paid for without emergency shelter voucher Other Don't Know or Refused 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 I, Chu; 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 HOPWA Eligible Individual Note: See definition of Tiansgender. Note: See definition of Beneficiaries. Data Check: The sure of each of the Charts b. & c. on the following two pages equals the total number of beneficiaries served with HOPWA housing subsidy assistance as determined in Chart a., Row 4 below. a. Total Number of Beneficiaries Served with HOPWA Housing Subsidy Assistance Individuals and Families Served with HOPWA Housing Subsidy Assistance 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 18 to 30 years 3. 31 to 50 years 51 years and 4. Older Subtotal (Sum of Rows 1-4) 6. Under 18 7. 18 to 30 years 8. 31 to 50 years 51 years and 9. Older Subtotal (Sum 10. of Rows 6-9) 11. of Rows 5 & 10) A. Male A. Male HOPWA Eligible Individuals (Chart a, Row 1) B. C. D. E. TOTAL (Sum of Female Transgender M to F Transgender F to M Columns A-D) All Other Beneficiaries (Chart a, Rows 2 and 3) B C. D. E. 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]. Report the ethnicity of all other individuals who benefitted from the HOPWA housing subsidy assistance in column [D]. The summed total of columns [A] and [C] equals the total number of beneficiaries reported above in Section 2, Chart a., Row 4. Category 1. American Indian/Alaskan Native 2. Asian 3. Black/African American 4. Native Hawaiian/Other Pacific Islander 5. White b. American Indian/Alaskan Native & White 7. I Asian & White 8. 1 Black/African American & White American Indian/Alaskan Native & Black/African American 10. I Other Multi -Racial 11. 1 Column Totals (Sum of Rows 1-10) 9. HOPWA Eligible Individuals [AJ Race [all individuals reported in Section 2, Chart a., Row 11 i [B] Ethnicity [Also identified as Hispanic or Latino] All Other Beneficiaries [C] Race [total of individuals reported in Section 2, Chart a., Rows 2 & 3] [DJ Ethnicity [Also identified as Hispanic or Latino] Data Check: Sum of Row 11 Column A and Row 11 Column C equals the total number HOPWA Benef ciaries reported in Part 3A, Section 2, Chart a., Row 4. *Reference (data requested consistent with Form HUD-27061 Race and Ethnic Data Reporting Form) Section 3. Households Household Area Median Income Report the area median income(s) for all households served with HOPWA housing subsidy assistance. Data Check: The total number of households served with HOPWA housing subsidy assistance should equal Part 3C, Row 7, Column b and Part 7A, Section 1, Chart a. (Total HOPWA Eligible Individuals Served with HOPWA Housing Subsidy Assistance). Note: Refer to httv://www.huduserorgthortal/datasets/iN12010/select Georanhv _nntl. odn for information on area median 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. 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 proErams originally developed with HOPWA funds but no longer supported with HOPWA funds. If a facility was developed with HOPWA funds (subject to ten years of operation for acquisition, new construction and substantial rehabilitation costs of stewardship units, or three years for non -substantial rehabilitation costs), but HOPWA funds are no longer used to support the facility, the project sponsor or subtecipient 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 on them as a group and under type ofFacility write `Scattered Sites." Name of Facility: Type of Development this operating year New construction 0 Rehabilitation ■ Acquisition ❑ Operating HOPWA Funds Expended this operating year (if applicable) $ Purchase/lease of property: Rehabilitation/Construction Dates: 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 Type of Facility [Check only one box.] Pennanent housing 0 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 started: ■ Not yet providing services Date Completed: HOPWA-funded units = Total Units = ❑ Yes LJ No Ifyes, number 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 required for each facility In Charts 3a. and 3b., indicate the type and number of housing units in the facility, including master leased units, project -based or other scattered site units leased by the organization, categorized by the number of bedrooms per unit. Note: The number units may not equal the total number of households served. Please complete separate charts for each housing facility assisted. Scattered site units may be grouped together. 3a. Check one only n Permanent Supportive Housing Facility/Units Short-term Shelter or Transitional Supportive Housing Facility/Units 3b. Type of Facility Complete the following Chart for all facilities leased, master leased, project -based, or operated with HOPWA funds during the reporting year Name of Project Sponsor/Agency Operating the Facility/Leased Units: Type of housing facility operated by the project sponsor/subrecipient a. Single room occupancy dwelling b. Community residence d. Project -based rental assistance units or leased units Other housing facility Specify: Total Number of Units in use during the Operating Year Categorized by the Number of Bedrooms per Units SRO/Studio/0 1 bdrm 2 bdrm 3 bdrm 4 bdrm 5+bdrm bdrm 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. 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 Output: Total HOPWA Funds Expended during Households Operating Year by Project Sponsor/subrecipient Page 25 form HUD-40110-D (Expiration Date: 10/31/2014) M&C Review Page 1 of 5 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: 17HUDACTPLANPY12-13 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; http://apps.cfwnet.org/council_packet/mc _rev iew.asp7ID=17008&councildate=8/7/2012 11/27/2012 M&C Review Page 2 of 5 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 - $8741517.85 This item includes social services for low to moderate income, disabled, and disadvantaged populations. http://apps.cfwnet.org/council_packet/mc review.asp?ID=17008&councildate=8/7/2012 11/27/2012 M&C Review Page 3 of 5 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 http://apps.cfwnet.org/council_packet/mc_review. asp?ID=1 70 0 8 &counc i ld ate=8/7/20 1 2 11 /27/2012 M&C Review Page 4 of 5 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 Emergency Solutions Grant: Table 2 - ESG Agencies Organization Catholic Charities of Fort Worth CFW: Parks and Community Services Presbyterian Night Shelter SafeHaven of Tarrant County Day Resource Center Diamond Hill and N orthside Station Volunteer Advocate Training S ubstance Abuse Treatment S chool 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 Obras Transportation for S eniors Community Kitchen/Meals Child Development P rogram Power of Self P roject Ramp Program P revention and Rapid Re -Housing Community Action P artners The Emergency Shelter Program Shelter Operations and Rapid Re -Housing Counseling Services and Case Management TOTAL ESG Contracts Housing Opportunities 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 http://apps.cfwnet.org/council_packet/mc_review. asp7ID=1700 8&councildate=8/7/2012 11/27/2012 M&C Review Page 5 of 5 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. adf List of Selected Streets for 2012-2013.odf http://apps.cfwnet.org/council_packet/mc review.asp7ID=17008&councildate=8/7/2012 11/27/2012