HomeMy WebLinkAboutContract 56617HOPWA PSA CONTRACT 2021-2022 Page 1
Tarrant County Samaritan House, Inc Rev. 8/18/2020
STATE OF TEXAS §
§
COUNTY OF TARRANT §
This contract (“Contract”) is made and entered into by and between the City of Fort Worth
(hereafter “City”) and Tarrant County Samaritan House, Inc. (hereafter “Agency”), a Texas non-
profit corporation. City and Agency may be referred to individually as a “Party” and jointly as “the
Parties”.
The Parties state as follows:
WHEREAS, City receives grant monies from the United States Department of Housing and
Urban Development through the Housing Opportunities for Persons with AIDS Program
(“HOPWA”) Program, Program No. TX-H-21-F002, Catalog of Federal Domestic Assistance No.
14.241;
WHEREAS, the HOPWA program is intended to address the needs of eligible persons
associated with the challenge of living with HIV/AIDS and their families;
WHEREAS, Agency submitted a proposal to use HOPWA funds for an eligible program
under the HOPWA Regulations whereby Agency will provide services to low and moderate income
persons;
WHEREAS, City citizens, the Community Development Council, and the City Council have
determined that HOPWA programs are needed by the City’s citizens;
NOW, THEREFORE, the Parties understand and agree as follows:
1.INCORPORATION OF RECITALS
City and Agency hereby agree that the recitals set forth above are true and correct and form
the basis upon which the Parties have entered into this Contract.
2.DEFINITIONS
In addition to terms defined in the body of this Contract, the terms set forth below shall
have the definitions ascribed to them as follows:
Area Median Income or AMI means the median family income for the Fort Worth-Arlington
metropolitan statistical area as established annually by HUD. The 2021 income limits are attached
hereto as EXHIBIT “A-1” – 2021 HUD Income Limits.
Business Diversity Enterprise Ordinance or BDE means the City’s Business Diversity Ordinance,
Ordinance No. 24534-11-2020, as may be amended from time to time.
Complete Documentation means the following documentation as applicable:
CSC No. 56617
HOPWA PSA CONTRACT 2021-2022 Page 2
Tarrant County Samaritan House, Inc Rev. 8/18/2020
• Attachments I, II, and III, with supporting documentation including:
o Proof of expense: copies of timesheets, invoices, leases, service contracts or
other documentation showing that payment is due by Agency.
o Proof of payment: cancelled checks, bank statements, or wire transfers
necessary to demonstrate that amounts due by Agency were actually paid by
Agency.
o Proof of client eligibility: Source Documentation sufficient to show that
clients participating in the Program are HOPWA Eligible Clients as described
in Section 6.
• Complete Documentation shall meet the standards described in the attached
EXHIBIT “F”- Standards for Complete Documentation.
• Any other document or record reasonably necessary to verify costs spent and client
eligibility for the Program.
DBE means disadvantaged business enterprise in accordance with 49 CFR Part 26.
Director means the Director of the City’s Neighborhood Services Department.
Effective Date means October 1, 2021.
HOPWA means Housing Opportunities for Persons with AIDS.
HOPWA Eligible Client means a client whose annual income adjusted for family size does not
exceed 80% of AMI using the most current HUD Income Guidelines and Technical Guidance for
Determining Income and Allowances verified by Source Documentation. The client must also have
a documented diagnosis of HIV/AIDS.
HOPWA Funds means the HOPWA grant funds supplied by City to Agency under the terms of
this Contract.
HOPWA Regulations means regulations found at 24 CFR Part 574 et seq.
HUD means the United States Department of Housing and Urban Development.
IDIS means Integrated Disbursement Information System, HUD’s project tracking system.
Neighborhood Services Department means the City’s Neighborhood Services Department.
Neighborly Software – Online database maintained by the City of Fort Worth through which
Agency is required to submit monthly reimbursement requests.
OMB means the Office of Management and Budget.
Program means the services described in EXHIBIT “A” – Program Summary.
HOPWA PSA CONTRACT 2021-2022 Page 3
Tarrant County Samaritan House, Inc Rev. 8/18/2020
Reimbursement Request means all reports and other documentation described in Section 9.
Source Documentation means documentation of full household income of any type described under
the definition of annual income in 24 CFR Part 5.609, including but not limited to copies of
paychecks, Social Security and disability verification letters, interest or rental income statements,
retirement income statements, child support and alimony verification, unemployment benefit letters,
and the like.
Unduplicated Clients means a count of HOPWA Eligible Clients served at least once in the
Contract Term. HOPWA Eligible Clients served more than once in the Contract Term will only be
counted the first time they are served when determining the total count of Unduplicated Clients.
3. TERM.
The term of this Contract (Contract Term) begins on the Effective Date and terminates on
September 30, 2022 unless earlier terminated as provided in this Contract. This Contract may be
extended, by the written mutual agreement of the Parties, if such extension is necessary for
completion of the program, or to amend the contracts 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. The Contract Term shall
include any extension, if exercised, as provided herein.
4. DUTIES AND RESPONSIBILITIES OF CITY.
4.1 Provide HOPWA Funds.
City shall provide up to $845,765.00 of HOPWA Funds under the terms and conditions of
this Contract.
4.2 Monitor.
City will monitor the activities and performance of Agency and any of its contractors,
subcontractors or vendors as necessary, but no less than annually. Monitoring by City will include
determining whether Agency is meeting the requirements of the HOPWA Regulations during the
term of this Contract.
5. DUTIES AND RESPONSIBILITIES OF AGENCY.
5.1 Required Services.
Agency shall perform the services described in EXHIBIT “A” – Program Summary in
accordance with the terms and conditions of this Contract.
5.2 Use of HOPWA Funds.
5.2.1. Compliance with HOPWA Regulations and Contract.
Agency shall be reimbursed for eligible Program costs with HOPWA Funds only if City
determines in its sole discretion that:
HOPWA PSA CONTRACT 2021-2022 Page 4
Tarrant County Samaritan House, Inc Rev. 8/18/2020
5.2.1.1 Costs are eligible expenditures in accordance with HOPWA Regulations.
5.2.1.2 Costs are in compliance with this Contract and are reasonable and consistent
with industry norms.
5.2.1.3 Complete Documentation, as applicable, is submitted to City by Agency.
5.2.2 Budget
5.2.2.1 The HOPWA Funds will be paid on a reimbursement basis in accordance
with EXHIBIT “B” - Budget.
5.2.2.2 During the term of this Contract, Agency may submit written requests to
increase or decrease line-item amounts in the Budget, including an
explanation of why such increases or decreases are necessary. All
requests shall be approved by Director in writing, with such approval
being in the Director’s sole discretion. If Director approves the Agency’s
proposed Budget amendment (as approved, the “Amended Budget”),
then the Amended Budget will take effect on the first day of the month
following the month in which it was approved by Director, unless
otherwise specified in the amendment. All requests for Budget
amendments must be submitted by June 1, 2022.
5.2.3 Change in Program Budget.
5.2.3.1 Agency will notify City promptly of any additional funds it receives for
operation of the Program, and City reserves the right to amend this
Contract in such instances to ensure compliance with HUD regulations
governing cost allocation.
5.2.3.2 Agency agrees to utilize the HOPWA Funds to supplement rather than
supplant funds otherwise available for the Program.
5.2.4 Payment of HOPWA Funds to Agency.
HOPWA Funds will be disbursed to Agency upon City’s approval of Reimbursement
Requests including submission of Complete Documentation to City in compliance with Section 9.
If Agency expends all funds budgeted for the Program prior to September 30, 2022, City may hold
back a small amount of the HOPWA Funds until the end of the term. During this interim period,
Agency must continue to submit Attachment III – Client Data Report in EXHIBIT “D” –
Reimbursement Forms monthly. It is expressly agreed by the Parties that any HOPWA Funds not
spent or not approved for reimbursement to Agency shall remain with City.
5.3 Program Performance Milestones.
5.3.1 Agency represents that the Program will achieve the following milestones in
accordance with EXHIBIT “A” – Program Summary and the table below:
HOPWA PSA CONTRACT 2021-2022 Page 5
Tarrant County Samaritan House, Inc Rev. 8/18/2020
Month Expenditures
Unduplicated Clients as
specified in EXHIBIT
“A” – Program
Summary
3 25% 25%
6 50% 50%
9 75% 75%
12 100% 100%
5.3.2 Failure of Agency to meet these milestones or a material deviation from them as
outlined in this Section 5.3 is a breach of this Contract. For the purpose of this Section, “material
deviation” shall mean more than 10% lower than the specified goal. In the event of such breach,
City reserves the right in its sole option to delay or withhold payment of Reimbursement Requests,
to lower Agency’s allocation of HOPWA Funds, or to terminate this Contract.
5.3.3 Failure to meet at least 80% of its performance milestones or serve 88 Unduplicated
Clients under this Contract may, in City’s sole discretion, disqualify Agency for consideration under
the City’s Request for Proposals for the 2022-2023 Program Year for federal grant funds.
5.3.4 Amendments to performance milestones regarding HOPWA funds must be approved
by the Director in writing, with such approval being in the Director’s sole discretion. If Director
approves the Agency’s proposed amended performance milestones (as approved, the “Amended
Performance Milestones”), then the Amended Performance Milestones will take effect on the
first day of the month following the month in which it was approved by Director, unless otherwise
specified in the amendment. All requests for amendments to performance milestones must be
submitted by June 1, 2022. Notwithstanding the above, any amendments to this Contract shall not
reduce the number of Unduplicated Clients stated in Section 5.3.3 and in EXHIBIT “A” – Program
Summary.
5.4 Identify Program Expenses Paid with HOPWA Funds.
Agency will keep accounts and records in such a manner that City may readily identify and
account for Program expenses reimbursed with HOPWA Funds. These records shall be made
available to City for audit purposes and shall be retained as required hereunder.
5.5 Program Subcontracts.
Agency shall not enter into a subcontract with another agency, contractor, or vendor to
provide a service to clients for any part of the Program that will be paid with HOPWA Funds without
City’s written consent.
6. CLIENT ELIGIBILITY VERIFICATION.
6.1 Client Eligibility.
Agency will document the eligibility of all prospective clients. Agency may redact the
client’s personal information and substitute a client number. Agency will document client eligibility
as follows:
HOPWA PSA CONTRACT 2021-2022 Page 6
Tarrant County Samaritan House, Inc Rev. 8/18/2020
6.1.1 Income.
Agency must verify all new clients' income eligibility with Source Documentation. Agency
must use the annual income definition used by 24 CFR Part 5.609 to establish client income
eligibility and must use the most current HUD Income Guidelines.
6.1.2 Diagnosis.
Agency must submit a signed, dated statement that the client's file contains documentation
of the client’s diagnosis of HIV/AIDS. The HIV/AIDS diagnosis must be made by a licensed health
care provider; a client's self-certification of diagnosis is not sufficient. Agency should not submit
the actual diagnosis to City.
6.1.3 Emergency Need.
For clients receiving short term rental, mortgage or utility assistance, Agency must also
verify and document that the client has an emergency need, such as sudden loss of income, eviction,
utility shutoff, or extraordinary and unexpected healthcare costs. Agency must submit its policy
regarding documenting emergency need to City by October 1, 2021.
6.2 Submission of Complete Documentation.
Agency must submit copies of documentation of client eligibility described in Section 6.1
with Attachment III in each month’s Reimbursement Request for all Unduplicated Clients.
6.3 Maintain Documentation.
Agency must maintain copies of all documentation required by this Section 6 for 5 years
following the expiration of the Contract term. This Section shall survive the earlier terminations or
expirations of this Contract.
7. ADDITIONAL HOPWA REQUIREMENTS.
Agency agrees to comply with all requirements of the HOPWA Program as stated in the
HOPWA Regulations, including but not limited to the following:
7.1 Environmental Review.
HOPWA Funds will not be paid, and costs cannot be incurred until City has conducted an
environmental review and completed an Environmental Review Record as required by 24 CFR Part
58. The environmental review may result in a decision to proceed with, modify, or cancel the
funding for the Program. Further, Agency will not undertake or commit any funds to physical or
choice limiting actions as described in any applicable federal regulations. Any violation of this
provision will (i) cause this Contract to terminate immediately; and (ii) require Agency to repay City
the HOPWA Funds it has already received and forfeit any future payments of HOPWA Funds.
7.2 Contract Not Constituting Commitment of Funds.
Notwithstanding any provision of this Contract, the Parties agree and acknowledge that this
Contract does not constitute a commitment of funds, and that such commitment of funds or approval
may occur only upon (i) satisfactory completion of an environmental review and receipt by City of
an authorization to use grant funds from HUD under 24 CFR Part 58, (ii) approval of City’s 2021 -
2022 Action Plan, and (iii) receipt by City of grant agreement from HUD.
HOPWA PSA CONTRACT 2021-2022 Page 7
Tarrant County Samaritan House, Inc Rev. 8/18/2020
7.3 Monitoring.
7.3.1 Agency understands and agrees that it will be subject to monitoring by City for
compliance with terms and provisions of this Contract and the HOPWA Regulations for the term
of this Contract. Agency is subject to such monitoring during the term of this Contract and for 5
years after the Contract term ends. For purposes of this Contract, unless this Contract is earlier
terminated, this 5 year period for monitoring is deemed to begin on October 1, 2022, or October 1,
2023 if the Contract is extended, and shall end no later than September 30, 2028. Agency will
provide reports and access to Program files as requested by City during this 5 year period.
7.3.2 Representatives of City, HUD, HUD Office of Inspector General, and the United
States Comptroller General shall have access during regular business hours, upon 48 hours prior
notice, to Agency’s offices and records pertaining to the use of the HOPWA Funds, and to Agency’s
officers, directors, agents, employees, contractors, subcontractors and vendors for the purpose of
such monitoring.
7.3.3 In addition to other provisions of this Contract regarding frequency of monitoring,
City reserves the right to perform desk reviews or on-site monitoring of Agency’s compliance with
the terms and conditions of this Contract. City shall provide Agency with a written report of the
monitor’s findings after each monitoring visit. If the monitoring report notes deficiencies in
Agency’s performance, the report shall include requirements for the timely correction of said
deficiencies by Agency. Failure by Agency to take the action specified in the monitoring report may
be cause for suspension or termination of this Contract as provided herein.
7.3.4 Subsections 7.3.1 through 7.3.3 shall be applicable for the Contract term and for 5
years thereafter and shall survive the earlier termination or expiration of this Contract.
7.3.5 Agency shall provide City annually the results of any state or federal monitoring.
Such results shall be submitted within 60 days of receipt of such state or federal monitoring report,
or with the January Reimbursement Request, whichever is earlier.
7.4 Agency Procurement Standards.
Agency shall comply with all applicable federal, state and local laws, regulations, and
ordinances for making procurements under this Contract. In addition to the conflict of interest
provision in Section 14.13.3, Agency shall establish written procurement procedures to ensure that
materials and services are obtained in a cost effective manner and that provides for full and open
competition. When procuring materials and services for this Contract, Agency shall comply at a
minimum with the procurement standards in 2 CFR Part 200.317 through 2 CFR Part 200.326.
7.4.1 Contracts in excess of $10,000.00 made by Agency using CDBG Funds must address
termination for cause and convenience including the manner by which such termination shall be
effected and the basis for settlement of the terminated contract, if any, as required by Appendix II
(B), 2 CFR Part 200.
7.4.2 Agency shall not make any contract with parties listed on the government wide
HOPWA PSA CONTRACT 2021-2022 Page 8
Tarrant County Samaritan House, Inc Rev. 8/18/2020
System for Award Management, www.sam.gov (“SAM”). Agency must confirm by search of
SAM that all contractors paid with CDBG Funds are not listed by SAM as being debarred, both prior
to hiring and prior to submitting a Reimbursement Request which includes invoices from any such
contractor. Failure to submit such proofs of search shall be an event of default.
7.5 Cost Principles/Cost Reasonableness.
Agency shall administer its use of HOPWA Funds in compliance with 2 CFR Part 200, as
applicable. The eligibility of costs incurred for performance rendered shall be determined in
accordance with 2 CFR Part 200.400 through 2 CFR Part 200.475.
7.6 Financial Management Standards.
Agency agrees to comply with 2 CFR Part 200, as applicable. Agency also agrees to adhere
to the accounting principles and procedures required therein, utilize adequate internal controls, and
maintain necessary supporting and back-up documentation for all costs incurred in accordance with
2 CFR Part 200.302 and Part 200.303.
7.7 Uniform Administrative Requirements, Cost Principles, and Audit
Requirements.
Agency will comply with the Uniform Administrative Requirements, Cost Principles, and
Audit Requirements for Federal Awards in 2 CFR Part 200, as applicable, or any reasonably
equivalent procedures and requirements that City may require.
7.8 Terms Applicable to Contractors, Subcontractors and Vendors.
Agency understands and agrees that all terms of this Contract, whether regulatory or
otherwise, shall apply to any and all contractors, subcontractors and vendors of Agency which are
in any way paid with HOPWA Funds or who perform any work in connection with the Program.
Agency shall cause all applicable provisions of this Contract to be included in and made a part of
any contract or subcontract executed in the performance of its obligations hereunder including its
obligations regarding the HOPWA Regulations. Agency shall monitor the services and work
performed by its contractors, subcontractors and vendors on a regular basis for compliance with the
HOPWA Regulations and Contract provisions. Agency must cure all violations of the HOPWA
Regulations committed by its contractors, subcontractors or vendors. City maintains the right to
insist on Agency’s full compliance with the terms of this Contract and the HOPWA Regulations and
Agency is responsible for such compliance regardless of whether actions taken to fulfill the
requirements of this Contract are taken by Agency or by Agency’s contractors, subcontractors or
vendors. Agency acknowledges that the provisions of this Section shall survive the earlier
termination or expiration of this Contract and shall be applicable for 5 years after the Contract Term
ends.
7.9 Copyright and Patent Rights.
No reports, maps, or other documents produced in whole or in part under this Contract shall
be the subject of an application for copyright by or on behalf of Agency. HUD and City shall possess
all rights to invention or discovery, as well as rights in data, which may arise as a result of Agency’s
performance under this Contract.
HOPWA PSA CONTRACT 2021-2022 Page 9
Tarrant County Samaritan House, Inc Rev. 8/18/2020
7.10 Conflict of Interest Disclosure.
In accordance with the requirements of Section 14.13.2.1 and 14.13.4, Agency shall establish
conflict of interest policies for federal awards. Agency shall disclose to City in writing any potential
conflict of interest.
7.11 Compliance with FFATA and Whistleblower Protections.
Agency shall comply with the requirements of 2 CFR 300(b), including provisions of the
Federal Funding Accountability and Transparency Act (“FFATA”) governing requirements on
executive compensation and provisions governing whistleblower protections contained in 10 U.S.C.
2409, 41 U.S.C. 4712, 10 U.S.C. 2324, 41 U.S.C. 4304 and 41 U.S.C. 4310.
7.11.1 Agency shall provide City with its DUNS number.
7.12 Internal Controls.
In compliance with the requirements of 2 CFR Part 200.303, Agency shall:
7.12.1 Establish and maintain effective internal control over the HOPWA Funds that
provides reasonable assurance that Agency is managing the HOPWA Funds in compliance with
federal statutes, regulations, and the terms and conditions of this Contract. These internal controls
shall be in compliance with guidance in “Standards for Internal Control in the Federal Government”
issued by the Comptroller General of the United States or the “Internal Control Integrated
Framework” issued by the Committee of Sponsoring Organizations of the Treadway Commission
(“COSO”);
7.12.2 Comply with federal statutes, regulations, and the terms and conditions of this
Contract;
7.12.3 Evaluate and monitor Agency’s compliance with statutes, regulations and the terms
and conditions of this Contract;
7.12.4 Take prompt action when instances of noncompliance are identified including
noncompliance identified in audit findings; and
7.12.5 Take reasonable measures to safeguard protected personally identifiable information
and other information that HUD or City designates as sensitive or Agency considers sensitive
consistent with applicable federal, state, local and tribal laws regarding privacy and obligations of
confidentiality.
7.13 Required Certification of Completion of Training.
At least 1 Agency employee must complete the HUD required “Getting to Work Training
Curriculum” by April 15, 2022 and submit the required certifications to City with the April 2022
Reimbursement Request as more particularly described on EXHIBIT “A-2” – Requirements for
Completion of “Getting to Work Training Curriculum”.
7.14 Housing Quality Standards.
All housing assisted under this Contract must meet housing quality standards and habitability
standards as required by 24 CFR Part 574.310(b). City shall have the right to inspect to confirm
HOPWA PSA CONTRACT 2021-2022 Page 10
Tarrant County Samaritan House, Inc Rev. 8/18/2020
compliance with these standards.
7.15. Violence Against Women Act Requirements
7.15.1 Agency shall comply with the Violence Against Women Act (“VAWA”) and shall
ensure that any property owner, manager, or facility assisted by the HOPWA Funds shall, at the time
of application for services, provide all clients receiving rental assistance with a Notice of Occupancy
Rights under the Violence Against Women Act in substantially the same form as the form attached
and incorporated as Exhibit “L”-Notice of Occupancy Rights Under VAWA in compliance with
VAWA and 24 CFR Part 574.604(a)(2), where applicable.
7.15.2 Agency agrees that no applicant for HOPWA assistance may be denied admission or
assistance under the Program on the basis or as a direct result of the fact that they are or have been
a victim of domestic violence, dating violence, sexual assault, or stalking, as long as they would
otherwise qualify for the Program.
7.15.3 Agency shall be responsible for reviewing VAWA and 24 CFR Part 574.604 and shall
respond to all emergency transfer requests in accordance with the requirements of those
provisions. Agency may request that all clients requesting an emergency transfer under VAWA fill
out the form attached and incorporated as Exhibit “M” – VAWA Emergency Transfer Request
Form.
7.15.4 Agency shall document and report to City any VAWA emergency transfer request
and outcome in compliance with 24 CFR Part 91.520 and 24 CFR Part 574
8. RECORD KEEPING; REPORTING AND DOCUMENTATION REQUIREMENTS;
AUDIT.
8.1 Record Keeping.
Agency shall maintain a record-keeping system as part of its performance of this Contract
and shall promptly provide City with copies of any document City deems necessary for the effective
fulfillment of City’s monitoring and evaluation responsibilities. Specifically, Agency will keep or
cause to be kept an accurate record of all actions taken and all funds spent, with supporting and back-
up documentation. Agency will maintain all records and documentation related to this Contract for
5 years after the Contract term ends. If any claim, litigation, or audit is initiated before the expiration
of the 5 year period, the relevant records and documentation must be retained until all such claims,
litigation or audits have been resolved. For purposes of this Contract, unless this Contract is earlier
terminated, this 5 year period for record retention is deemed to begin on October 1, 2022, or October
1, 2023 if the Contract is extended, and shall end no later than September 30, 2028.
8.2 Access to Records.
Representatives of City, HUD and any duly authorized officials of the federal government
will have full access to, and the right to examine, audit, copy, excerpt and/or transcribe any of
Agency’s records pertaining to all matters covered by this Contract for 5 years after the Contract
term ends. Such access shall be during regular business hours and upon at least 48 hours prior notice.
HOPWA PSA CONTRACT 2021-2022 Page 11
Tarrant County Samaritan House, Inc Rev. 8/18/2020
For purposes of this Contract, unless this Contract is earlier terminated, this 5 year period for access
to records is deemed to begin on October 1, 2022, or October 1, 2023 if the Contract is extended,
and shall end no later than September 30, 2028.
8.3 Reports.
Agency will submit to City all reports and documentation described in this Contract in such
form as City may prescribe. Agency may also be required to submit a final performance and/or final
financial report if required by City at the termination of this Contract in such form and within such
times as City may prescribe. Failure to submit to City any report or documentation described in this
Contract shall be an event of default of this Contract and City may exercise all of its remedies for
default under this Contract.
8.3.1 Additional Information.
Agency shall provide City with additional information as may be required by state or federal
agencies to substantiate Program activities and/or expenditure eligibility.
8.4 Change in Reporting Requirements and Forms
City retains the right to change reporting requirements and forms at its discretion. City will
notify Agency in writing at least 15 days prior to the effective date of such change, and the Parties
shall execute an amendment to the Contract reflecting such change if necessary.
8.5 Audit
8.5.1 Entities that Expend $750,000 or more in Federal Funds Per Year
All non-federal entities that expend $750,000 or more in federal funds within 1 year,
regardless of the source of the federal award, must submit to City an annual audit prepared in
accordance with specific reference to 2 CFR Part 200.501 through Part 200.521. The audit shall
cover the Agency’s fiscal years during which this Contract is in force. The audit must be prepared
by an independent certified public accountant, be completed within 6 months following the end of
the period being audited and be submitted to City within 30 days of its completion. Agency’s audit
certification is attached hereto as EXHIBIT “C” – “Audit Certification Form” and “Audit
Requirements”. The Audit Certification Form must be submitted to City prior to or with the first
Reimbursement Request. Entities that expend less than $750,000 a year in federal funds are exempt
from federal audit requirements for that year, but records must be available for review or audit by
appropriate officials of the federal agency, City, and General Accounting Office.
HOPWA PSA CONTRACT 2021-2022 Page 12
Tarrant County Samaritan House, Inc Rev. 8/18/2020
8.5.2 City Reserves the Right to Audit.
City reserves the right to perform an audit of Agency’s Program operations and finances at
any time during the term of this Contract and for 5 years after the Contract Term ends if City
determines that such audit is necessary for City’s compliance with the HOPWA Regulations or other
City policies. Agency agrees to allow access to all pertinent materials as described herein for such
audit. For purposes of this Contract, unless this Contract is earlier terminated, this 5 year period for
City audit is deemed to begin on October 1, 2022, or October 1, 2023 if the Contract is extended,
and shall end no later than September 30, 2028. If such audit reveals a questioned practice or
expenditure, such questions must be resolved within 15 business days after notice to Agency of such
questioned practice or expenditure. If questions are not resolved within this period, City reserves
the right to withhold further funding under this Contract and/or any other contracts with Agency. IF
AS A RESULT OF ANY AUDIT IT IS DETERMINED THAT AGENCY HAS FALSIFIED
ANY DOCUMENTATION OR MISUSED, MISAPPLIED OR MISAPPROPRIATED
HOPWA FUNDS OR SPENT HOPWA FUNDS ON ANY INELIGIBLE ACTIVITIES,
AGENCY AGREES TO REIMBURSE CITY THE AMOUNT OF SUCH MONIES PLUS
THE AMOUNT OF ANY SANCTIONS, PENALTY OR OTHER CHARGE LEVIED
AGAINST CITY BY HUD BECAUSE OF SUCH ACTIONS.
9. REIMBURSEMENT REQUIREMENTS
9.1 Deadline for Submitting Reimbursement Requests.
9.1.1 Reimbursement Requests shall be submitted monthly to the City and must be
received by the City on or before the 15th day of the month following the month expenses were paid
by Agency. For example, the Reimbursement Request for June expenses must be received by July
15. In the event the 15th falls on a weekend or City holiday, Reimbursement Requests shall be due
the next day that the City is open for business. Failure to submit a Reimbursement Request in a
timely fashion will result in City taking the actions outlined in Section 11.1.
NOTWITHSTANDING ANYTHING ABOVE, THE REIMBURSEMENT REQUEST FOR
EXPENSES INCURRED FOR SEPTEMBER 2022 MUST BE RECEIVED BY OCTOBER 1,
2022. COMPLETE DOCUMENTATION FOR ALL SEPTEMBER 2021 EXPENSES MUST
BE SUBMITTED BY OCTOBER 15, 2022. FAILURE TO SUBMIT A FINAL
REIMBURSEMENT REQUEST WITH COMPLETE DOCUMENTATION BY OCTOBER
15, 2021 WILL RESULT IN FORFEITURE OF PAYMENT OF THE SEPTEMBER
REIMBURSEMENT REQUEST.
9.1.2 City will notify Agency by e-mail within 14 calendar days if a Reimbursement
Request is lacking Complete Documentation or corrections are needed. Agency will have 7 business
days from the date of the e-mail notice to submit any requested information or missing
documentation. Agency may be penalized, at City’s sole discretion, in the Request for Proposal for
the 2022-2023 Program Year for any notifications received under this Section. If Agency fails to
submit all the required information or missing documentation within 30 calendar days from the first
e-mail, Agency shall forfeit any payments otherwise due that month and failure to submit any
requested information will be considered an event of default as outlined in Section 10.1.2.
HOPWA PSA CONTRACT 2021-2022 Page 13
Tarrant County Samaritan House, Inc Rev. 8/18/2020
9.2 Submission of Reimbursement Requests.
Agency shall provide City with Complete Documentation and the following reports as shown
in EXHIBIT “D” – Reimbursement Forms with each Reimbursement Request:
9.2.1 Attachment I – Invoice
This report shall contain the amount requested for reimbursement each month, the
cumulative reimbursement requested to date (inclusive of that month’s request).
9.2.1.1 Agency must submit a separate invoice for each activity type, i.e.
Administration, Facility Based Operating Costs, Supportive Services,
Short-term Rent, Mortgage and Utility Assistance (“STRMU”), and
Tenant Based Rental Assistance (“TBRA”).
9.2.2 Attachment II – Expenditure Worksheet
This report shall itemize each expense requested for reimbursement by Agency and shall
include the Account corresponding the expense to a Budget line item. In order for this report to be
complete the following must be submitted:
9.2.2.1 For payroll expenses, timesheets signed by employees and approved by
supervisor for all payroll expenses listed. Timesheets must distinguish
between HOPWA-funded time and non-HOPWA funded time and reflect
actual time spent on HOPWA-funded activities. Agency may not submit
payroll expenses dated 60 calendar days prior to the date of the
Reimbursement Request.
9.2.2.2 For non-payroll expenses, invoices for each expense listed with an
explanation as to how the invoiced expense pertains to the Program.
Agency may not submit invoices dated 60 calendar days prior to the date
of the Reimbursement Request.
9.2.2.3 Proof that each expense was paid by Agency, which proof can be satisfied
by canceled checks, wire transfer documentation, paid receipts or other
appropriate banking documentation.
9.2.3 Attachment III – Client Data Report.
This report shall list each Unduplicated Client served during the month along with his or her
demographic information. The Client Data Report must maintain a list of all clients served during
the Contract term. If Agency, receives funds from the United States Department of Justice or the
Victims of Crime Act, then Agency is prohibited from submitting the Client Data Report to the City.
However, Agency must complete all required forms under Section 9.2.3 and maintain in client files
in accordance with Section 8. In order for this report to be complete, the following must be
submitted:
9.2.3.1 Documentation of income verification for each Unduplicated Client the
first time the client is served by the Program, which will be Source
Documentation.
HOPWA PSA CONTRACT 2021-2022 Page 14
Tarrant County Samaritan House, Inc Rev. 8/18/2020
9.2.4 Overview Report.
Agency shall submit the Overview, Report, attached hereto as EXHIBIT “H” – Overview
Report, quarterly with the December, March, June and September Reimbursement Requests.
9.2.5 Delivery of Reimbursement Request.
Reimbursement Requests will be submitted through Neighborly Software on the
designated due date.
9.3 Withholding Payment.
CITY SHALL HAVE NO OBLIGATION TO PAY ANY REIMBURSEMENT
REQUEST THAT IS NOT RECEIVED BY THE DUE DATE. Failure to timely submit
accurate and complete Reimbursement Requests and Complete Documentation along with any
required reports shall be an event of default.
10. DEFAULT AND TERMINATION.
10.1 Failure to Submit Reimbursement Request or Required Documentation.
10.1.1 If Agency fails to submit a Reimbursement Request in accordance with Section
9, Agency shall be in default of this Contract. City will notify Agency in writing of such default and
the Agency will have 7 calendar days from the date of the written notice to submit such
Reimbursement Request to cure the default. If Agency fails to cure the default within such time,
Agency shall forfeit any payments otherwise due that month.
10.1.2 If Agency fails to submit requested information or missing documentation as set
forth in Section 9.1.2, then Agency shall forfeit payment due that month and the failure to submit
shall be considered an event of default that shall not be cured.
10.1.3 NOTWITHSTANDING THE PROVISIONS OF SECTION 10.1.1 OR
10.1.2, IF AGENCY FAILS TO SUBMIT THE REIMBURSEMENT REQUEST DUE
OCTOBER 1, 2022, OR IF THE SUBMITTED REIMBURSEMENT REQUEST FOR
OCTOBER 1, 2022 IS LATE, INCOMPLETE OR OTHERWISE NOT IN COMPLIANCE
WITH THIS CONTRACT OR THE HOPWA REGULATIONS AS DETERMINED BY
CITY IN ITS SOLE DISCRETION, THERE WILL BE NO CURE PERIOD AND ANY
REIMBURSEMENT WILL BE FORFEITED.
10.1.4 In the event of (i) an uncured default under Section 10.1.1 or an event of default
under 10.1.2 (ii) or more than 2 instances of default, cured or uncured, under these Sections, City
reserves the right at its sole option to terminate this Contract effective immediately upon written
notice of such intent with no penalty or liability to City.
10.1.5 Notwithstanding anything to the contrary herein, City will not be required to pay
any HOPWA Funds to Agency during the period that any Reimbursement Request, report or
documentation is past due or is not in compliance with this Contract or the HOPWA Regulations, or
during any period during which Agency is in default of this Contract.
HOPWA PSA CONTRACT 2021-2022 Page 15
Tarrant County Samaritan House, Inc Rev. 8/18/2020
10.1.6 In the event of termination under this Section 10.1, all HOPWA Funds awarded
but unpaid to Agency pursuant to this Contract shall be immediately forfeited and Agency shall have
no further right to such funds.
10.2 Failure to Maintain Records or Submit Reports and Documentation.
If Agency fails to maintain all records and documentation as required in Section 8, or if the
maintained or submitted report or documentation is not in compliance with this Contract or the
HOPWA Regulations as determined by City in its sole discretion, City will notify Agency in writing
and Agency will have 30 calendar days from the date of the written request to obtain or recreate the
missing records and documentation or submit or resubmit any such report or documentation to City.
If Agency fails to maintain the required reports or documentation, or fails to submit or resubmit any
such report or documentation within such time, City shall have the right to terminate this Contract
effective immediately upon written notice of such intent with no penalty or liability to City.
10.2.1 In the event of termination under this Section 10.2, all HOPWA Funds awarded
but unpaid to Agency pursuant to this Contract shall be immediately forfeited and Agency shall have
no further right to such funds, and any HOPWA Funds paid to Agency must be repaid to City within
30 days of termination. If such HOPWA funds are not repaid to City within the 30 day period, City
shall exercise all legal remedies available under this Contract.
10.3 In General.
10.3.1 Subject to Section 10.2, and unless specifically provided otherwise in this
Contract, Agency shall be in default under this Contract if Agency breaches any term or condition
of this Contract. In the event that such a breach remains uncured after 30 calendar days following
written notice by City (or such other notice period as may be specified herein) or, if Agency has
diligently and continuously attempted to cure following receipt of such written notice but reasonably
requires more than 30 calendar days to cure, as determined by both Parties mutually and in good
faith, City shall have the right to elect in City’s sole discretion to (i) extend Agency’s time to cure,
(ii) terminate this Contract effective immediately upon written notice of such intent to Agency, or
(iii) pursue any other legal remedies available to City under this Contract.
10.3.2 City’s remedies may include:
10.3.2.1 Direct Agency to prepare and follow a schedule of actions for carrying
out the affected activities, consisting of schedules, timetables and
milestones necessary to implement the affected activities.
HOPWA PSA CONTRACT 2021-2022 Page 16
Tarrant County Samaritan House, Inc Rev. 8/18/2020
10.3.2.2 Direct Agency to establish and follow a management plan that assigns
responsibilities for carrying out the remedial activities.
10.3.2.3 Reprogram HOPWA Funds that have not yet been expended from
affected activities to other eligible activities or withhold HOPWA
Funds.
10.3.2.4 Any other appropriate action including but not limited to any remedial
action legally available such as declaratory judgment, specific
performance, damages, temporary or permanent injunctions,
termination of this Contract or any other contracts with Agency, and
any other available remedies.
10.3.3 In the event of termination under this Section 10.3, all HOPWA Funds awarded
but unpaid to Agency pursuant to this Contract shall be immediately forfeited and Agency shall have
no further right to such funds, and any HOPWA Funds already paid to Agency must be repaid to
City within 30 days of the termination. Failure to repay such HOPWA Funds within the 30 day
period will result in City exercising all legal remedies available under this Contract.
10.4 No Funds Disbursed while in Breach.
Agency understands and agrees that no HOPWA Funds will be paid to Agency until all
defaults are cured to City’s satisfaction.
10.5 No Compensation After Date of Termination.
Agency shall not receive any compensation for work undertaken after the date of the
termination.
10.6 Rights of City Not Affected.
Termination shall not affect or terminate any of the existing rights of City against Agency,
or which may thereafter accrue because of Agency’s default and this provision shall be in addition
to any and all other rights and remedies available to City under the law. Such termination does not
terminate any provisions of this Contract that have been expressly noted as surviving the term or
termination of the Contract. No delay or omission by City in exercising any right or remedy
available to it under this Contract shall impair any such right or remedy or constitute a waiver or
acquiescence in any Agency default.
10.7 Waiver of Breach Not Waiver of Subsequent Breach
The waiver of a default or breach of any term, covenant, or condition of this Contract shall
not operate as a waiver of any subsequent default or breach of the same or any other term, covenant
or condition hereof.
10.8 Civil, Criminal and Administrative Penalties
Failure to perform all the Contract terms may result in civil, criminal or administrative
penalties, including, but not limited to those set out in this Contract.
HOPWA PSA CONTRACT 2021-2022 Page 17
Tarrant County Samaritan House, Inc Rev. 8/18/2020
10.9 Termination for Cause
10.9.1 City may terminate this Contract in the event of Agency’s default, inability, or
failure to perform subject to notice, grace and cure periods. In the event City terminates this Contract
for cause, all HOPWA Funds awarded but unpaid to Agency pursuant to this Contract shall be
immediately rescinded and Agency shall have no further right to such funds and any HOPWA Funds
already paid to Agency must be repaid to City within 30 days of termination. Failure to repay such
HOPWA Funds within 30 days will result in City exercising all legal remedies available to City
under this Contract. AGENCY ACKNOWLEDGES AND AGREES THAT IF CITY
TERMINATES THIS CONTRACT FOR CAUSE, AGENCY OR ANY AFFILIATES OF
AGENCY SHALL NOT BE CONSIDERED FOR ANY OTHER CITY CONTRACT FOR
HOPWA FUNDS FOR A MINIMUM OF 5 YEARS FROM THE DATE OF TERMINATION.
11.9.2 Agency may terminate this Contract if City does not provide the HOPWA Funds
substantially in accordance with this Contract.
10.10 Termination for Convenience.
In terminating in accordance with 2 CFR Part 200, Appendix II, this Contract may be
terminated in whole or in part only as follows:
10.10.1 By City with the consent of Agency in which case the Parties shall agree upon
the termination conditions, including the effective date and in the case of partial termination, the
portion to be terminated; or
10.10.2 By Agency upon at least 30 days written notification to City, setting forth the
reasons for such termination, the effective date, and in the case of partial termination, the portion to
be terminated. In the case of a partial termination, City may terminate the Contract in its entirety if
City determines in its sole discretion that the remaining portion of the Contract to be performed or
HOPWA Funds to be spent will not accomplish the purposes for which the Contract was made.
10.11 Dissolution of Agency Terminates Contract.
This Contract shall terminate in the event Agency is dissolved or ceases to exist. In the event
of termination under this Section, all HOPWA Funds are subject to repayment and/or City may
exercise all of its remedies under this Contract.
10.13 Reversion of Assets.
In the event this Contract is terminated with or without cause, all assets acquired by Agency
with the HOPWA Funds including cash, interest payments from loans or otherwise, all outstanding
notes, mortgages or other security instruments, any accounts receivable attributable to the use of the
HOPWA Funds, and any real or personal property owned by Agency that was improved with the
HOPWA Funds shall automatically transfer to City or to such assignee as City may designate.
11. REPAYMENT OF HOPWA FUNDS.
All HOPWA Funds are subject to repayment in the event the Program does not meet the
requirements of this Contract or in the HOPWA Regulations. If Agency takes any action that
HOPWA PSA CONTRACT 2021-2022 Page 18
Tarrant County Samaritan House, Inc Rev. 8/18/2020
results in the City being required to repay all or any portion of the HOPWA Funds to HUD,
Agency agrees it will reimburse City within thirty days of notice from the City for such
repayment. Additionally, if Agency takes any action that results in City receiving a finding
from HUD about the Program, whether or not repayment of all or any portion of the HOPWA
Funds is required of City, Agency agrees City may require that 10% of the HOPWA Funds be
repaid to City as liquidated damages. The Parties agree that City’s damages in the event of either
repayment to HUD being required or receiving a finding from HUD are uncertain and would be
difficult to ascertain and may include an impact on City’s HOPWA grant or other federal grant funds,
in addition to the finding by HUD or a required repayment of funds to HUD by City. Therefore, the
Parties agree that payment under this Section of 10% of the HOPWA Funds by Agency to City is
liquidated damages and not a penalty.
12. CHANGE IN NON-PROFIT STATUS.
Agency must provide City with written notification of any changes to its non-profit status
within 15 calendar days of being notified of the change. Regardless of notice by Agency, if the non-
profit status of Agency changes after the date of this Contract, City may but is not obligated to,
terminate this Contract. In the event of termination under this Section 12, all HOPWA Funds
awarded but not yet paid to Agency pursuant to this Contract shall be immediately rescinded and
Agency shall have no further right to such funds. City, in its sole discretion, may require that any
HOPWA Funds already paid to Agency must be repaid to City within 30 calendar days of
termination under this Section.
13. SURVIVAL.
Any provision of this Contract that pertains to auditing, monitoring, indemnity obligations,
client income eligibility, record keeping and reports, City ordinances, or applicable HOPWA
requirements, and any default and enforcement provisions necessary to enforce such provisions,
shall survive the termination of this Contract for 5 years after the Contract term ends and shall be
enforceable by City against Agency. For purposes of this Contract, unless this Contract is earlier
terminated, this 5 year period for survival of certain Contract provisions is deemed to begin on
October 1, 2022, or October 1, 2023, if this contract is extended and end no later than September
30, 2028.
14. GENERAL PROVISIONS.
14.1 Agency an Independent Contractor.
Agency shall operate hereunder as an independent contractor and not as an officer, agent,
servant or employee of City. Agency shall have exclusive control of, and the exclusive right to
control, the details of the work and services performed hereunder, and all persons performing same,
and shall be solely responsible for the acts and omissions of its officers, members, agents, servants,
employees, contractors, subcontractors, vendors, clients, licensees or invitees.
14.2 Doctrine of Respondeat Superior.
The doctrine of respondeat superior shall not apply as between City and Agency, or its
officers, members, agents, servants, employees, contractors, subcontractors, vendors, clients,
licensees or invitees, and nothing herein shall be construed as creating a partnership or joint
HOPWA PSA CONTRACT 2021-2022 Page 19
Tarrant County Samaritan House, Inc Rev. 8/18/2020
enterprise between City and Agency. City does not have the legal right to control the details of the
tasks performed hereunder by Agency, its officers, members, agents, employees, contractors,
subcontractors, vendors, clients, licensees or invitees.
14.3 Agency Property.
City shall under no circumstances be responsible for any property belonging to Agency, or
its officers, members, agents, employees, contractors, subcontractors, vendors, clients, licensees or
invitees that may be lost, stolen or destroyed or in any way damaged and AGENCY HEREBY
INDEMNIFIES AND HOLDS HARMLESS CITY AND ITS OFFICERS, AGENTS, AND
EMPLOYEES FROM ANY AND ALL CLAIMS OR SUITS PERTAINING TO OR
CONNECTED WITH SUCH PROPERTY.
14.5 Religious Organization.
Agency shall comply with all applicable requirements as more particularly described in 24
CFR Part 5.109. No portion of the HOPWA Funds shall be used in support of any sectarian or
religious activity. In addition, there must be no religious or membership criteria for clients of a
HOPWA-funded service.
14.5.1. Separation of Explicitly Religious Activities.
Agency retains its independence and may continue to carry out its mission, including the
definition, development practice, and expression of its religious beliefs, provided that it does not use
HOPWA Funds to support or engage in any explicitly religious activities (including activities that
involve overt religious content such as worship, religious instruction, or proselytization), or in any
other manner prohibited by law.
14.5.2 Explicitly Religious Activities.
If Agency engages in explicitly religious activities (including activities that involve overt
religious content such as worship, religious instruction, or proselytization), the explicitly religious
activities must be offered separately, in time or location, from the programs or activities supported
by HOPWA Funds and participation must be voluntary for clients of a HOPWA-funded service.
14.5.3 Required Notices.
If Agency constitutes a Faith-based organization under 24 CFR Part 5.109, Agency must
provide all clients of a HOPWA-funded service with the notice attached as EXHIBIT “K”—Notice
of Beneficiary Rights. Such notice shall be provided to the client prior to enrollment in any
HOPWA-funded program or activity. In addition, if a client or prospective client of a HOPWA-
funded service objects to the religious character of Agency, then Agency must promptly undertake
reasonable efforts to identify and refer the client or prospective client to an alternate provider to
which the client or prospective client has no such objection, as more particularly described in 24
CFR Part 5.109.
14.6 Venue.
HOPWA PSA CONTRACT 2021-2022 Page 20
Tarrant County Samaritan House, Inc Rev. 8/18/2020
Venue shall lie in state courts located in Tarrant County, Texas or the United States District Court
for the Northern District of Texas, Fort Worth Division for any action, whether real or asserted, at law
or in equity, arising out of the execution, performance, attempted performance or non-performance
of this Contract.
14.7 Governing Law.
This Contract shall be governed by and construed in accordance with the laws of the State of
Texas. If any action, whether real or asserted, at law or in equity, arises out of the execution,
performance or non-performance of this Contract or on the basis of any provision herein, for any
issue not governed by federal law, the choice of law shall be the laws of the State of Texas.
14.8 Severability.
The provisions of this Contract are severable, and if for any reason a clause, sentence,
paragraph or other part of this Contract shall be determined to be invalid by a court or federal or
state agency, board or commission having jurisdiction over the subject matter thereof, such invalidity
shall not affect other provisions which can be given effect without the invalid provision.
14.9 Written Agreement Entire Contract.
This written instrument and the Exhibits, Attachments, and Addendums attached hereto,
which are incorporated by reference and made a part of this Contract for all purposes, constitute the
entire agreement by the Parties concerning the work and services to be performed under this
Contract. Any prior or contemporaneous oral or written agreement which purports to vary the terms
of this Contract shall be void. Any amendments to the terms of this Contract must be in writing and
executed by the Parties.
14.10 Paragraph Headings for Reference Only, No Legal Significance; Number
and Gender.
The paragraph headings contained herein are for convenience in reference to this Contract
and are not intended to define or to limit the scope of any provision of this Contract. When context
requires, singular nouns and pronouns include the plural and the masculine gender shall be deemed
to include the feminine or neuter and the neuter gender to include the masculine and feminine. The
words “include” and “including” whenever used herein shall be deemed to be followed by the words
“without limitation”.
14.11 Compliance With All Applicable Laws and Regulations.
Agency agrees to comply fully with all applicable laws and regulations that are currently in
effect or that are hereafter amended during the performance of this Contract. Those laws include,
but are not limited to:
HOPWA Regulations found in 24 CFR Part 574
AIDS Housing Opportunity Act, as amended (42 USC 12901 et seq.)
Title VI of the Civil Rights Act of 1964 (42 U.S.C. Sections 2000d et seq.) including
provisions requiring recipients of federal assistance to ensure meaningful access by
persons of limited English proficiency
The Fair Housing Act, Title VIII of the Civil Rights Act of 1968 (42 U.S.C. Sections
3601 et seq.)
HOPWA PSA CONTRACT 2021-2022 Page 21
Tarrant County Samaritan House, Inc Rev. 8/18/2020
Executive Orders 11063, 11246 as amended by 11375 and 12086 and as supplemented
by Department of Labor regulations 41 CFR Part 60
The Age Discrimination in Employment Act of 1967
The Age Discrimination Act of 1975 (42 U.S.C. Sections 6101 et seq.)
The Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970
(42 U.S.C. Sections 4601 et seq. and 49 CFR Part 24) (“URA”)
Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. Sections 794 et seq.) and 24
CFR Part 8 where applicable
National Environmental Policy Act of 1969, as amended, 42 U.S.C. Sections 4321 et seq.
(“NEPA”) and the related authorities listed in 24 CFR Part 58.
The Clean Air Act, as amended, (42 U.S.C. Sections 1251 et seq.) and the Clean Water
Act of 1977, as amended (33 U.S.C. Sections 1251 et seq.) and the related Executive
Order 11738. In no event shall any amount of the assistance provided under this Contract
be utilized with respect to a facility that has given rise to a conviction under the Clean
Air Act or the Clean Water Act.
Immigration Reform and Control Act of 1986 (8 U.S.C. Sections 1101 et seq.)
specifically including the provisions requiring employer verifications of legal status of
its employees
The Americans with Disabilities Act of 1990 (42 U.S.C. Sections 12101 et seq.), the
Architectural Barriers Act of 1968 as amended (42 U.S.C. Sections 4151 et seq.) and the
Uniform Federal Accessibility Standards, 24 CFR Part 40, Appendix A
Regulations at 24 CFR Part 87 related to lobbying, including the requirement that
certifications and disclosures be obtained from all covered persons
Drug Free Workplace Act of 1988 (41 U.S.C. Sections 701 et seq.) and 24 CFR Part 23,
Subpart F
Executive Order 12549 and 24 CFR Part 5.105(c) pertaining to restrictions on
participation by ineligible, debarred or suspended persons or entities
Section 6002 of the Solid Waste Disposal Act, as amended by the Resource Conservation
and Recovery Act
Guidelines of the Environmental Protection Agency at 40 CFR Part 247
For contracts and subgrants for construction or repair, Copeland “Anti-Kickback” act (18
U.S.C. 874) as supplemented in 29 CFR Part 5
For construction contracts awarded by Agency in excess of $2,000, and in excess of
$2,500 for other contracts which involve the employment of mechanics or laborers,
Sections 103 and 107 of the Contract Work Hours and Safety Standards Act (40 U.S.C.
327A 300) as supplemented by 29 CFR Part 5
Lead-Based Paint Poisoning Prevention Act (42 U.S.C. 4801 et seq.), as amended by the
Residential Lead-Based Paint Hazard Reduction Act of 1992 (42 U.S.C. 4851 et seq.)
and implementing regulations at 24 CFR Part 35, subparts A, B, M, and R
Uniform Administrative Requirements, Cost Principles, and Audit Requirements for
Federal Awards, 2 CFR Part 200 et seq.
Federal Funding Accountability and Transparency Act of 2006 (“FFATA”) (Pub.L. 109-
282, as amended by Section 6205(a) of Pub.L. 110-252 and Section 3 of Pub.L. 113-101)
Federal Whistleblower Regulations, as contained in 10 U.S.C. 2409, 41 U.S.C. 4712, 10
U.S.C. 2324, 41 U.S.C. 4304 and 41 U.S.C. 4310.
HOPWA PSA CONTRACT 2021-2022 Page 22
Tarrant County Samaritan House, Inc Rev. 8/18/2020
14.12 HUD-Assisted Projects and Employment and other Economic
Opportunities; Section 3 Requirements.
14.13 Prohibition Against Discrimination.
14.13.1 General Statement.
Agency shall comply in the execution, performance or attempted performance of this
Contract, with all non-discrimination requirements of 24 CFR Part 574.603 and Chapter 17, Article
III, Division 4 – Fair Housing of the City Code. Agency may not discriminate against any person
because of race, color, sex, gender, religion, national origin, familial status, disability or perceived
disability, sexual orientation, gender identity, gender expression, or transgender, nor will Agency
permit its officers, members, agents, employees, or clients to engage in such discrimination.
This Contract is made and entered into with reference specifically to Chapter 17, Article III,
Division 3 - Employment Practices of the City Code, and Agency hereby covenants and agrees that
Agency, its officers, members, agents, employees and contractors, have fully complied with all
provisions of same and that no employee, or applicant for employment has been discriminated
against under the terms of such ordinances by either or its officers, members, agents, employees or
contractors.
14.13.2 No Discrimination in Employment during the Performance of This Contract.
During the performance of this Contract Agency agrees to the following provision, and will
require that its contractors and subcontractors also comply with such provision by including it in all
contracts with its contractors:
[Contractor’s, Subcontractor’s or Vendor’s name] will not unlawfully discriminate against
any employee or applicants for employment because of race, color, sex, gender, religion, national
origin, familial status, disability or perceived disability, sexual orientation, gender identity, gender
expression or transgender. [Contractor’s, Subcontractor’s or Vendor’s name]will take affirmative
action to ensure that applicants are hired without regard to race, color, sex, gender, religion, national
origin, familial status, disability or perceived disability, sexual orientation, gender identity, gender
expression or transgender and that employees are treated fairly during employment without regard
to their race, color, sex, gender, religion, national origin, familial status, disability or perceived
disability, sexual orientation, gender identity, gender expression or transgender. Such action shall
include, but not be limited to, the following: employment, upgrading, demotion or transfer,
recruitment or recruitment advertising, layoff or termination, rates of pay or other forms of
compensation, and selection for training, including apprenticeship. [Contractor’s, Subcontractor’s
or Vendor’s name] agrees to post in conspicuous places, available to employees and applicants for
employment, notices setting forth the provisions of this nondiscrimination clause.
[Contractor’s Subcontractor’s or Vendor’s name] will, in all solicitations or advertisements
for employees placed by or on behalf of [Contractor’s, Subcontractor’s or Vendor’s name], state
that all qualified applicants will receive consideration for employment without regard to race, color,
sex, gender, religion, national origin, familial status, disability or perceived disability, sexual
orientation, gender identity, gender expression or transgender.
[Contractor’s, Subcontractor’s or Vendor’s name] covenants that neither it nor any of its
HOPWA PSA CONTRACT 2021-2022 Page 23
Tarrant County Samaritan House, Inc Rev. 8/18/2020
officers, members, agents, employees, or contractors, while engaged in performing this Contract,
shall, in connection with the employment, advancement or discharge of employees or in connection
with the terms, conditions or privileges of their employment, discriminate against persons because
of their age or because of any disability or perceived disability, except on the basis of a bona fide
occupational qualification, retirement plan or statutory requirement.
[Contractor’s, Subcontractor’s or Vendor’s name] further covenants that neither it nor its
officers, members, agents, employees, contractors, or persons acting on their behalf, shall specify,
in solicitations or advertisements for employees to work on this Contract, a maximum age limit for
such employment unless the specified maximum age limit is based upon a bona fide occupational
qualification, retirement plan or statutory requirement.
14.13.3 Agency’s Contractors and the ADA.
In accordance with the provisions of the Americans With Disabilities Act of 1990 (“ADA”),
Agency warrants that it and any of its contractors will not unlawfully discriminate on the basis of
disability in the provision of services to the general public, nor in the availability, terms and/or
conditions of employment for applicants for employment with, or employees of, Agency or any of
its contractors. AGENCY WARRANTS IT WILL FULLY COMPLY WITH THE ADA’S
PROVISIONS AND ANY OTHER APPLICABLE FEDERAL, STATE AND LOCAL LAWS
CONCERNING DISABILITY AND WILL DEFEND, INDEMNIFY AND HOLD CITY
HARMLESS AGAINST ANY CLAIMS OR ALLEGATIONS ASSERTED BY THIRD
PARTIES, CONTRACTORS SUBCONTRACTORS, VENDORS OR AGENTS AGAINST
CITY ARISING OUT OF AGENCY’S AND/OR ITS CONTRACTORS’,
SUBCONTRACTORS’, VENDORS’ OR AGENTS’ OR THEIR RESPECTIVE
EMPLOYEES’ ALLEGED FAILURE TO COMPLY WITH THE ABOVE-REFERENCED
LAWS CONCERNING DISABILITY DISCRIMINATION IN THE PERFORMANCE OF
THIS CONTRACT.
14.14. Conflicts of Interest and Violations of Criminal Law.
14.14.1 Agency Safeguards.
Agency shall establish safeguards to prohibit its employees, board members, advisors and
agents from using positions for a purpose that is or gives the appearance of being motivated by a
desire for private gain for themselves or others, particularly those with whom they have family,
business or other ties. Agency shall disclose to City any such conflict of interest or potential conflict
of interest, immediately upon discovery of such.
14.14.2 General Prohibitions Against Conflicts of Interest.
No employees, agents, consultants, officers or elected officials or appointed officials of City
or of Agency who exercise or have exercised any functions or responsibilities with respect to
activities assisted with HOPWA funds or who are in a position to participate in a decision-making
process or gain inside information with regard to these activities may utilize HOPWA services, may
obtain a financial interest or benefit from a HOPWA-assisted activity, or have an interest in any
contract, subcontract or agreement with respect thereto, or the proceeds thereunder, either for
themselves or those with whom they have family or business ties, during their tenure or for 1 year
thereafter.
HOPWA PSA CONTRACT 2021-2022 Page 24
Tarrant County Samaritan House, Inc Rev. 8/18/2020
14.14.2.1 Agency shall establish conflict of interest policies for federal awards
including the CDBG Funds and shall disclose in writing potential
conflicts of interest to City as authorized by 2 CFR Part 200.112.
14.14.3 Conflicts of Interest Involving Procurement.
The conflict of interest provisions of 2 CFR Part 200.318, shall apply in the procurement of
property and services by Agency. In all cases not governed by those Sections, the provisions of 24
CFR Part 574.625 of the HOPWA Regulations shall apply.
14.14.3.1 As more particularly described in 2 CFR Part 200.318, Agency shall
maintain and submit to City written standards of conduct covering
conflicts of interest and governing the performance of its employees
engaged in the selection, award, and administration of contracts. No
employee, officer, or agent may participate in the selection, award, or
administration of a contract supported by a federal award if he or she
has a real or apparent conflict of interest. The standards of conduct
must provide for disciplinary actions to be applied for violations of
such standards by officers, employees, or agents of Agency.
14.14.3.2 The officers, employees, and agents of Agency shall neither solicit nor
accept gratuities, favors, or anything of monetary value from
contractors or parties to subcontracts.
14.14.3.3 Notwithstanding the prohibition contained in Section 14.13.3.2,
Agency may set standards of conduct for situations in which the
financial interest is not substantial or the gift is an unsolicited item of
nominal value. Such standards of conduct must provide for
disciplinary actions to be applied for violations of such standards by
Agency’s officers, employees or agents.
14.14.3.4 Agency shall maintain written standards of conduct covering
organizational conflicts of interest. Organizational conflicts of
interest means that because of relationships with a parent company,
affiliate, or subsidiary organization, Agency is unable or appears to be
unable to be impartial in conducting a procurement action involving a
related organization.
14.14.3.5 Agency must maintain records sufficient to detail the history of
procurement. These records will include, but are not necessarily
limited to the following: rationale for the method of procurement,
selection of contract type, contractor selection or rejection, and the
basis for the contract price.
HOPWA PSA CONTRACT 2021-2022 Page 25
Tarrant County Samaritan House, Inc Rev. 8/18/2020
14.14.4 Disclosure of Conflicts of Interest.
In compliance with 2 CFR Part 200.112, Agency is required to timely disclose to City in
writing any potential conflict of interest.
14.14.5 Disclosure of Texas Penal Code Violations.
Agency affirms that it will adhere to the provisions of the Texas Penal Code which prohibit
bribery and gifts to public servants.
14.14.6 Disclosure of Federal Criminal Law Violations.
In compliance with 2 CFR Part 200.113, Agency is required to timely disclose to City all
violations of federal criminal law involving fraud, bribery or gratuity violations potentially affecting
the Agency.
14.15 Subcontracting with Small and Minority Firms, Women’s Business
Enterprises and Labor Surplus Areas.
14.15.1 For procurement contracts $50,000.00 or larger that are paid for, in part or in full,
with HOPWA Funds, Agency agrees to abide by City’s policy to involve Minority Business
Enterprises and Small Business Enterprises and to provide them equal opportunity to compete for
contracts for construction, provision of professional services, purchase of equipment and supplies
and provision of other services required by City. Agency agrees to incorporate the City’s BDE
Ordinance, and all amendments or successor policies or ordinances thereto, into all contracts and
subcontracts for procurement larger than $50,000.00 or larger that are paid for, in part or in full, with
the HOPWA Funds and will further require all persons or entities with which it so contracts to
comply with said ordinance.
14.15.2 It is national policy to award a fair share of contracts to disadvantaged business
enterprises (“DBEs”), small business enterprises (“SBEs”), minority business enterprises
(“MBEs”), and women’s business enterprises (“WBEs”). Accordingly, affirmative steps must be
taken to assure that DBEs, SBEs, MBEs, and WBEs are utilized when possible as sources of
supplies, equipment, construction and services.
14.15.2.1 In order to comply with federal reporting requirements, Agency must
submit the form attached hereto as EXHIBIT “I” – MBE Reporting
Form for each contract or subcontract with a value of $10,000.00 or
more paid or to be paid with the HOPWA Funds. Agency shall submit
this form by the date specified in EXHIBIT “I” – MBE Reporting
Form.
14.16 Other Laws.
The failure to list any federal, state or City ordinance, law or regulation that is applicable to
Agency does not excuse or relieve Agency from the requirements or responsibilities in regard to
following the law, nor from the consequences or penalties for Agency’s failure to follow the law, if
applicable.
HOPWA PSA CONTRACT 2021-2022 Page 26
Tarrant County Samaritan House, Inc Rev. 8/18/2020
14.17 Assignment.
Agency shall not assign all or any part of its rights, privileges, or duties under this Contract
without the prior written approval of City. Any attempted assignment of same without approval
shall be void, and shall constitute a breach of this Contract.
14.18. Right to Inspect Agency Contracts.
It is agreed that City has the right to inspect and approve in writing any proposed contracts
between Agency and any contractor or vendor engaged in any activity in conjunction with this
HOPWA-funded Program prior to any charges being incurred.
14.19 Force Majeure
If Agency becomes unable, either in whole or part, to fulfill its obligations under this Contract
due to acts of God, strikes, lockouts, or other industrial disturbances, acts of public enemies, wars,
blockades, insurrections, riots, epidemics, pandemics, earthquakes, fires, floods, restraints or
prohibitions by any court, board, department, commission or agency of the United States or of any
States, civil disturbances, or explosions, or some other reason beyond Agency’s control (collectively,
“Force Majeure Event”), the obligations so affected by such Force Majeure Event will be
suspended only during the continuance of such event. Agency will give City written notice of the
existence, extent and nature of the Force Majeure Event as soon as reasonably possible after the
occurrence of the event. Failure to give notice will result in the continuance of Agency’s obligation
regardless of the extent of any existing Force Majeure Event. Agency will use commercially
reasonable efforts to remedy its inability to perform as soon as possible.
14.20 IMMIGRATION NATIONALITY ACT.
Agency shall verify the identity and employment eligibility of its employees who perform
work under this Contract, including completing the Employment Eligibility Verification Form (I-
9). Upon request by City, Agency shall provide City with copies of all I-9 forms and supporting
eligibility documentation for each employee who performs work under this Contract. Agency shall
adhere to all Federal and State laws as well as establish appropriate procedures and controls so that
no services will be performed by any Agency employee who is not legally eligible to perform such
services. AGENCY SHALL INDEMNIFY CITY AND HOLD CITY HARMLESS FROM
ANY PENALTIES, LIABILITIES, OR LOSSES DUE TO VIOLATIONS OF THIS
PARAGRAPH BY AGENCY, AGENCY’S EMPLOYEES, SUBCONTRACTORS, AGENTS,
OR LICENSEES. City, upon written notice to Agency, shall have the right to immediately
terminate this Contract for violations of this provision by Agency.
15. INDEMNIFICATION AND RELEASE.
AGENCY COVENANTS AND AGREES TO INDEMNIFY, HOLD HARMLESS AND
DEFEND, AT ITS OWN EXPENSE, CITY AND ITS OFFICERS, AGENTS, SERVANTS
AND EMPLOYEES FROM AND AGAINST ANY AND ALL CLAIMS OR SUITS FOR
PROPERTY LOSS OR DAMAGE AND/OR PERSONAL INJURY, INCLUDING DEATH,
TO ANY AND ALL PERSONS, OF WHATSOEVER KIND OR CHARACTER, WHETHER
REAL OR ASSERTED, ARISING OUT OF OR IN CONNECTION WITH THE
EXECUTION, PERFORMANCE, ATTEMPTED PERFORMANCE OR
NONPERFORMANCE OF THIS CONTRACT AND/OR THE OPERATIONS, ACTIVITIES
HOPWA PSA CONTRACT 2021-2022 Page 27
Tarrant County Samaritan House, Inc Rev. 8/18/2020
AND SERVICES OF THE PROGRAM DESCRIBED HEREIN, WHETHER OR NOT
CAUSED IN WHOLE OR IN PART, BY ALLEGED NEGLIGENCE OF OFFICERS,
AGENTS, SERVANTS, EMPLOYEES, CONTRACTORS OR SUBCONTRACTORS OF
CITY; AND AGENCY HEREBY ASSUMES ALL LIABILITY AND RESPONSIBILITY OF
CITY AND ITS OFFICERS, AGENTS, SERVANTS, AND EMPLOYEES FOR ANY AND
ALL CLAIMS OR SUITS FOR PROPERTY LOSS OR DAMAGE AND/OR PERSONAL
INJURY, INCLUDING DEATH, TO ANY AND ALL PERSONS, OF WHATSOEVER
KINDS OR CHARACTER, WHETHER REAL OR ASSERTED, ARISING OUT OF OR IN
CONNECTION WITH THE EXECUTION, PERFORMANCE, ATTEMPTED
PERFORMANCE OR NONPERFORMANCE OF THIS CONTRACT AND/OR THE
OPERATIONS, ACTIVITIES AND SERVICES OF THE PROGRAM DESCRIBED
HEREIN, WHETHER OR NOT CAUSED IN WHOLE OR IN PART BY ALLEGED
NEGLIGENCE OF OFFICERS, AGENTS, SERVANTS, EMPLOYEES, CONTRACTORS
OR SUBCONTRACTORS OF CITY. AGENCY LIKEWISE COVENANTS AND AGREES
TO AND DOES HEREBY INDEMNIFY AND HOLD HARMLESS CITY FROM AND
AGAINST ANY AND ALL INJURY, DAMAGE OR DESTRUCTION OF PROPERTY OF
CITY, ARISING OUT OF OR IN CONNECTION WITH ALL ACTS OR OMISSIONS OF
AGENCY, ITS OFFICERS, MEMBERS, AGENTS, EMPLOYEES, CONTRACTORS,
SUBCONTRACTORS, INVITEES, LICENSEES, OR CLIENTS, OR CAUSED, IN WHOLE
OR IN PART, BY ALLEGED NEGLIGENCE OF OFFICERS, AGENTS, SERVANTS,
EMPLOYEES, CONTRACTORS OR SUBCONTRACTORS OF CITY.
IT IS THE EXPRESS INTENTION OF THE PARTIES, BOTH AGENCY AND CITY,
THAT THE INDEMNITY PROVIDED FOR THIS SECTION INCLUDES INDEMNITY BY
AGENCY TO INDEMNIFY AND PROTECT CITY FROM THE CONSEQUENCES OF
CITY’S OWN NEGLIGENCE, WHETHER THAT NEGLIGENCE IS ALLEGED TO BE
THE SOLE OR CONCURRING CAUSE OF THE INJURY, DAMAGE OR DEATH.
AGENCY AGREES TO AND SHALL RELEASE CITY, ITS AGENTS,
EMPLOYEES, OFFICERS AND LEGAL REPRESENTATIVES FROM ALL LIABILITY
FOR INJURY, DEATH, DAMAGE OR LOSS TO PERSONS OR PROPERTY SUSTAINED
IN CONNECTION WITH OR INCIDENTAL TO PERFORMANCE UNDER THIS
CONTRACT, EVEN IF THE INJURY, DEATH, DAMAGE OR LOSS IS CAUSED BY
CITY’S SOLE OR CONCURRENT NEGLIGENCE.
AGENCY SHALL REQUIRE ALL OF ITS CONTRACTORS AND
SUBCONTRACTORS TO INCLUDE IN THEIR CONTRACTS AND SUBCONTRACTS A
RELEASE AND INDEMNITY IN FAVOR OF CITY IN SUBSTANTIALLY THE SAME
FORM AS ABOVE.
16. WAIVER OF IMMUNITY BY AGENCY.
If Agency, as a charitable or nonprofit organization, has or claims an immunity or exemption
(statutory or otherwise) from and against liability for damages or injury, including death, to persons
or property, Agency hereby expressly waives its rights to plead defensively such immunity or
exemption as against City. This Section shall not be construed to affect a governmental entity’s
immunities under constitutional, statutory or common law.
HOPWA PSA CONTRACT 2021-2022 Page 28
Tarrant County Samaritan House, Inc Rev. 8/18/2020
17. INSURANCE AND BONDING.
Agency will maintain coverage in the form of insurance or bond in the amount of
$845, 765.00 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 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
the following insurance coverage and limits:
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
HOPWA PSA CONTRACT 2021-2022 Page 29
Tarrant County Samaritan House, Inc Rev. 8/18/2020
Note: Such insurance shall cover employees performing work on any and all projects
including but not limited to construction, demolition, and rehabilitation. Agency or its
contractors shall maintain coverages, if applicable. In the event the respective contractors
do not maintain coverage, Agency shall maintain the coverage on such contractor, if
applicable, for each applicable contract.
Additional Requirements
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.
Any failure on part of City to request certificate(s) of insurance shall not be construed as a waiver
of such requirement or as a waiver of the insurance requirements themselves.
Insurers of Agency’s insurance policies shall be licensed to do business in the state of Texas by the
Department of Insurance or be otherwise eligible and authorized to do business in the state of Texas.
Insurers shall be acceptable to City insofar as their financial strength and solvency and each such
company shall have a current minimum A.M. Best Key Rating Guide rating of A-: VII or other
equivalent insurance industry standard rating otherwise approved by City.
Deductible limits on insurance policies shall not exceed $5,000 per occurrence unless otherwise
approved by City.
In the event there are any local, federal or other regulatory insurance or bonding requirements for
the Program, and such requirements exceed those specified herein, the former shall prevail.
Agency shall 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 in judgment, breaches of duty and wrongful acts arising
out of their organizational duties. Coverage shall protect not only the entity, but all past, present and
future directors, officers, trustees, employees, volunteers and committee members.
HOPWA PSA CONTRACT 2021-2022 Page 30
Tarrant County Samaritan House, Inc Rev. 8/18/2020
Notwithstanding any provision in this Contract to the contrary, when applicable, Agency shall
comply with the requirements of 2 CFR 200.310 and shall, at a minimum, provide the
equivalent insurance coverage for real property and equipment acquired or improved with
CDBG Funds as provided to property owned by Agency.
18. CERTIFICATION REGARDING LOBBYING.
The undersigned representative of Agency hereby certifies, to the best of his or her
knowledge and belief, that:
No federal appropriated funds have been paid or will be paid, by or on behalf of Agency, to
any person for influencing or attempting to influence an officer or employee of any agency,
a member of Congress, an officer or employee of Congress in connection with the awarding
of any federal contract, the making of any federal grant, the making of any federal loan, the
entering into of any cooperative agreement and the extension, continuation, renewal,
amendment, or modification of any federal contract, grant, loan or cooperative agreement.
If any funds other than federally appropriated funds have been paid or will be paid to any
person for influencing or attempting to influence an officer or employee of any agency,
member of Congress in connection with this federal contract, grant, loan or cooperative
agreement, Agency shall complete and submit Standard Form-LLL, “Disclosure Form to
Report Lobbying,” in accordance with its instructions.
This certification is a material representation of fact upon which reliance was placed when
this Contract was made or entered into. Submission of this certificate is a prerequisite for
making or entering into this Contract imposed by 31 U.S.C. Section 1352. Any person who
fails to file the required certification shall be subject to a civil penalty of not less than
$10,000.00 and not more than $100,000.00 for each such failure.
Agency shall require that the language of this certification be included in all subcontracts or
agreements involving the expenditure of federal funds.
19. LITIGATION AND CLAIMS.
Agency shall give City immediate notice in writing of any action, including any proceeding
before an administrative agency, filed against Agency in conjunction with this Contract or the
Program. Agency shall furnish immediately to City copies of all pertinent papers received by
Agency with respect to such action or claim. Agency shall provide a notice to City within 10 days
upon filing under any bankruptcy or financial insolvency provision of law.
20. NOTICE
All notices required or permitted by this Contract must be in writing and are deemed delivered
on the earlier date of the date actually received or the third day following deposit in a United States
Postal Service post office or receptacle; with proper postage, certified mail return receipt requested;
HOPWA PSA CONTRACT 2021-2022 Page 31
Tarrant County Samaritan House, Inc Rev. 8/18/2020
and addressed to the other Party at the address set out below or at such other address as the receiving
Party designates by proper notice to the sending Party.
City:
City Attorney’s Office
200 Texas Street
Fort Worth, TX 76102
Telephone: 817-392-7600
Copy to:
Director of Neighborhood Services Department
200 Texas Street
Fort Worth, TX 76102
Attention: Assistant Director
Telephone: 817-392-7540
Copy to:
Neighborhood Services Department
200 Texas Street
Fort Worth, TX 76102
Attention: Contract Administrator
Telephone: 817-392-5812
Agency:
Tarrant County Samaritan House, Inc.
Contact: Kimberly Robinson
929 Hemphill Street
Fort Worth, TX 76104
Telephone: 817-332-6410
21. AGENCY HAS LEGAL AUTHORITY TO ENTER INTO CONTRACT.
Agency represents that it possesses the legal authority, pursuant to any proper, appropriate
and official motion, resolution or action passed or taken, to enter into this Contract and to perform
the responsibilities herein required.
22. COUNTERPARTS.
This Contract may be executed in multiple counterparts, each of which shall be considered
an original, but all of which shall constitute one instrument which may be sufficiently evidenced by
one counterpart.
23. PROGRAM INCOME
Parties agree that no program income as defined by HUD shall be earned as a result of this
contract.
HOPWA PSA CONTRACT 2021-2022 Page 32
Tarrant County Samaritan House, Inc Rev. 8/18/2020
24. PROHIBITION ON CONTRACTING WITH COMPANIES THAT BOYCOTT ISRAEL
If Agency has less than ten employees, this contract is for less than $100,000, or Agency
does not meet the definition of a “company” under the applicable section of the Texas Government
Code, this provision shall not apply. Agency acknowledges that in accordance with Chapter 2270 of
the Texas Government Code, the City is prohibited from entering into a contract with a company for
goods or services unless the contract contains a written verification from the company that it: (1)
does not boycott Israel; and (2) will not boycott Israel during the term of the contract. The terms
“boycott Israel” and “company” shall have the meanings ascribed to those terms in Section 808.001
of the Texas Government Code. By signing this contract, Agency certifies that Agency’s signature
provides written verification to the City that Agency: (1) does not boycott Israel; and (2) will not
boycott Israel during the term of the contract.
25. PROHIBITION ON BOYCOTTING ENERGY COMPANIES
Agency acknowledges that in accordance with Chapter 2274 of the Texas Government Code,
as added by Acts 2021, 87th Leg., R.S., S.B. 13, § 2, the City is prohibited from entering into a
contract for goods or services that has a value of $100,000 or more that is to be paid wholly or partly
from public funds of the City with a company with 10 or more full-time employees unless the
contract contains a written verification from the company that it: (1) does not boycott energy
companies; and (2) will not boycott energy companies during the term of the contract. The terms
“boycott energy company” and “company” have the meaning ascribed to those terms by Chapter
2274 of the Texas Government Code, as added by Acts 2021, 87th Leg., R.S., S.B. 13, § 2. To the
extent that Chapter 2274 of the Government Code is applicable to this Agreement, by signing this
Agreement, Agency certifies that Agency’s signature provides written verification to the City that
Agency: (1) does not boycott energy companies; and (2) will not boycott energy companies during
the term of this Agreement.
26. PROHIBITION ON DISCRIMINATION AGAINST FIREARM AND
AMMUNITION INDUSTRIES
Agency acknowledges that except as otherwise provided by Chapter 2274 of the Texas
Government Code, as added by Acts 2021, 87th Leg., R.S., S.B. 19, § 1, the City is prohibited from
entering into a contract for goods or services that has a value of $100,000 or more that is to be paid
wholly or partly from public funds of the City with a company with 10 or more full-time employees
unless the contract contains a written verification from the company that it: (1) does not have a
practice, policy, guidance, or directive that discriminates against a firearm entity or firearm trade
association; and (2) will not discriminate during the term of the contract against a firearm entity or
firearm trade association. The terms “discriminate,” “firearm entity” and “firearm trade association”
have the meaning ascribed to those terms by Chapter 2274 of the Texas Government Code, as added
by Acts 2021, 87th Leg., R.S., S.B. 19, § 1. To the extent that Chapter 2274 of the Government
Code is applicable to this Agreement, by signing this Agreement, Agency certifies that Agency’s
signature provides written verification to the City that Agency: (1) does not have a practice, policy,
guidance, or directive that discriminates against a firearm entity or firearm trade association; and (2)
HOPWA PSA CONTRACT 2021-2022 Page 33
Tarrant County Samaritan House, Inc Rev. 8/18/2020
will not discriminate against a firearm entity or firearm trade association during the term of this
Agreement.
[SIGNATURES APPEAR ON NEXT PAGE]
HOPWA PSA CONTRACT 2021-2022 Page 34
Tarrant County Samaritan House, Inc Rev. 8/18/2020
IN WITNESS WHEREOF, the Parties hereto have executed 4 duplicate originals of this
Contract in Fort Worth, Tarrant County, Texas.
ATTEST: CITY OF FORT WORTH
_________________________________ By: _____________________________________
City Secretary Fernando Costa, Assistant City Manager
M&C: 21-0522
1295 Certification No. 2021-725009
Date: August 3, 2021
RECOMMENDED BY:
_____________________________
Victor Turner
Director of Neighborhood Services Department
APPROVED AS TO FORM AND LEGALITY:
_________________________________
Taylor Paris, Assistant City Attorney
CONTRACT COMPLIANCE MANAGER:
By signing, I acknowledge that I am the person responsible
for the monitoring and administration of this contract, including
ensuring all performance and reporting requirements
_________________________________________
Barbara Asbury
Compliance and Planning Manager
TARRANT COUNTY SAMARITAN HOUSE, INC.
B y: _____________________________
Kimberly Robinson, President and CEO
Kim Robinson (Nov 5, 2021 12:05 CDT)
Kim Robinson
Barbara Asbury (Nov 5, 2021 14:01 CDT)
Barbara Asbury
Fernando Costa (Nov 8, 2021 10:51 CST)
HOPWA PSA CONTRACT 2021-2022 Page 35
Tarrant County Samaritan House, Inc Rev. 8/18/2020
EXHIBITS:
EXHIBIT “A” – Program Summary
EXHIBIT “A-1” – 2021 HUD Income Limits
EXHIBIT “A-2” - Requirements for Completion of “Getting to Work Training Curriculum”
EXHIBIT “B” – Budget
EXHIBIT “C” – Audit Certification Form
EXHIBIT “D” – Reimbursement Forms
EXHIBIT “E” – Form of Income Self-Certification
EXHIBIT “F” – Standards for Complete Documentation
EXHIBIT “G” – Section 3 Reporting Forms (NOT APPLICABLE)
EXHIBIT “H” – Overview Report
EXHIBIT “I” – MBE Reporting Form
EXHIBIT “J” – Duties of the Parties for Use of NSD Community Centers
EXHIBIT “K” – Notice of Beneficiary Rights
EXHIBIT “L” – Notice of Occupancy Rights Under VAWA
EXHIBIT “M” –VAWA Emergency Transfer Request Form
HOPWA PSA CONTRACT 2021-2022 ― EXHIBIT “A” ― PROGRAM SUMMARY Page 1
Tarrant County Samaritan Housing, Inc.
TARRANT COUNTY SAMARITAN HOUSING,
INC.
EXHIBIT “A”
Services for People Living with HIV/AIDS PROGRAM SUMMARY
PROGRAM SUMMARY
(HOPWA)
October 1, 2021 to September 30, 2022 $845,765
PERIOD AMOUNT
Capitalized terms not defined herein shall have meanings assigned them in the Contract.
PROGRAM:
The Program provides supportive services and Tenant Based Rental Assistance (TBRA) to
HOPWA-Eligible Clients living in the Samaritan Villages Apartments, the Samaritan House
Single Room Occupancy (“SRO”) Facility, and in scattered-site rental-voucher supported housing.
The supportive services include case management and housing counseling. Program services may
also include congregate meals; substance abuse counseling; medical transportation; recreational
and social programs; educational programs; and life and job skills programs.
TBRA includes long-term monthly rental assistance. Clients must be Income Eligible according
to HUD guidelines, live in a rental unit that passes habitability inspections, and have an identified
housing need as determined by the client’s case manager.
HOPWA Funds will pay for direct assistance for TBRA clients. HOPWA Funds will be used to
pay for a percentage of supportive service salaries and fringe benefits, associated with the Program.
HOPWA Funds will also be used to pay for the operational expenses of the Agency’s SRO Facility
located at 929 Hemphill Street, Fort Worth, TX 76104. Operational expenses consist of salaries
and fringe benefits for property management and maintenance staff.
No more than 7% of the HOPWA Funds will be used to pay for administrative costs, including
salaries and fringe benefits and City-required insurance associated with the Program.
Agency’s office and Program services will be available at 929 Hemphill Street, Fort Worth, Texas
76104, Monday through Friday, 9:00 a.m. to 5:00 p.m. Program services may also be provided at
clients’ homes. The SRO is staffed 24 hours a day, 7 days a week.
The Program will provide services to HOPWA-Eligible clients residing in Tarrant, Johnson,
Parker, Wise, Hood and Somervell counties.
REGULATORY CLASSIFICATION:
IDIS matrix Code(s) and Service Category: 31D HOPWA Project Sponsor Administration
31C HOPWA Project Sponsor Activity
HOPWA PSA CONTRACT 2021-2022 ― EXHIBIT “A” ― PROGRAM SUMMARY Page 2
Tarrant County Samaritan Housing, Inc.
Regulatory Citation(s): 24 CFR 574.300(b)(10) – Administrative Expenses
24 CFR 574.300(b)(7) – Supportive Services
24 CFR 574.300(b)(8) Facility Based Operations
24 CFR 574.300(b)(6) – TBRA
Agency will maintain documentation which verifies that 100% of clients served by the Program
are eligible under HOPWA Regulations.
PROGRAM GOALS:
Minimum Number of Clients to be Served: The Program must provide Supportive Services to
a minimum of 110 Unduplicated Clients. Unduplicated Clients must be residents of Tarrant,
Johnson, Parker, Wise, Hood and Somervell counties as shown by the monthly reports on
Attachment III. The Program will also provide Facility Based Housing Subsidy Assistance
through the housing operations to 60 household housing units and TBRA services to a minimum
of 14 households.
HOPWA PSA CONTRACT 2021-2022 - EXHIBIT “A-1” 2021 INCOME LIMITS Page 1
TARRANT COUNTY SAMARITAN HOUSING, INC.
EXHIBIT "A-1”
2021 HUD INCOME LIMITS
1 person 2 persons 3 persons 4 persons 5 persons 6 persons 7 persons 8 persons
30% AMI $17,000 $19,400 $21,960 $26,500 $31,040 $35,580 $40,120 $44,660
50% AMI $28,300 $32,350 $36,400 $40,400 $43,650 $46,900 $50,100 $53,350
80% AMI $45,300 $51,750 $58,200 $64,650 $69,850 $75,000 $80,200 $85,350
*Income limits are published at least annually by HUD.
HOPWA PSA CONTRACT 2021-2022 Page 1
EXHIBIT “A-2” REQUIREMENTS FOR COMPLETION OF “GETTING TO WORK TRAINING CURRICULUM”
Tarrant County Samaritan Housing, Inc.
EXHIBIT “A-2”
REQUIREMENTS FOR COMPLETION OF “GETTING TO WORK TRAINING
CURRICULUM”
HOPWA PSA CONTRACT 2020-21 Page 1
EXHIBIT “A-2” REQUIREMENTS FOR COMPLETION OF “GETTING TO WORK TRAINING CURRICULUM
Tarrant County Samaritan Housing, Inc.
Getting to Work:
A Training Curriculum for HIV/AIDS Service Providers and Housing Providers
At least 1 Agency employee must complete this required training curriculum by the deadline of April
15, 2022. Proof of completion must be submitted with the April reimbursement request.
The Getting to Work Training Curriculum is divided into 3 online modules:
Module 1: Understanding the Value of Work
Module 2: Adopting an Employment and Training Mindset – Organizationally and Individually
Module 3: Incorporating Employment into the HIV/AIDS Service Menu
To view the modules:
1. Click the module title.
2. You will be prompted to either create or log into your HUD Exchange Learn account.
3. Follow this guidance when creating a HUD Exchange account:
Step 1 of 2 screen: Fill out the required Personal Information, and Login Information sections.
For the Organization Information, if you are not affiliated with a HUD program, choose None
of the Above and I am an Individual.
Step 2 of 2 screen: All HUD Program Experience fields on the Learner Profile page are
optional. Click Update to complete the account creation process.
4. After creating an account or logging in, you will enter the HUD Exchange Learn system.
5. Click the Enroll button on the HUD Exchange Learn course description to access the course.
6. The module name will appear under Activities. Click the Module Name to access the course.
7. The module will launch in a new window, so please make sure your pop-up blockers are
turned off.
To receive credit for completing each module:
1. Take the completion quiz under Activities on the HUD Exchange Learn course description.
Each module has a quiz.
2. Score 80% or better on the quiz. You may take the quiz multiple times.
3. After you pass the quiz, you will be able to print a completion certificate on the HUD
Exchange Learn course description.
You can access information about the modules by visiting the HUD Exchange website at
www.hudexchange.com or by using the following link: https://www.hudexchange.info/training-
events/dol-hud-getting-to-work-curriculum-for-hiv-aids-providers. You may also contact your
assigned contract administrator to get additional information.
HOPWA PSA CONTRACT 2021 - EXHIBIT "B" - BUDGET
Page 1
Account Grant Budget A B C Total
PERSONNEL
Salaries 1001 37,789.00$ $ 19,479.00 492,826.00$ 550,094.00$
FICA 1002 2,891.00$ $ 1,490.00 37,701.00$ 42,082.00$
Life/Disability Insurance 1003 26.00$ $ 13.00 416.00$ 455.00$
Health/Dental Insurance 1004 3,214.00$ $ 1,071.00 59,982.00$ 64,267.00$
Unemployment-State 1005 $ - 5,501.00$ 5,501.00$
Worker's Compensation 1006 $ - 11,002.00$ 11,002.00$
Retirement 1,134.00$ $ 584.00 $ - $ 14,785.00 16,503.00$
Contract Labor-Accounting 1007 $ - 12,240.00$ 12,240.00$
Mileage 1008 $ - -$
Insurance-Commercial Umbrella
Liability 1009 $ 4,500.00 25,000.00$ 29,500.00$
Insurance-Directors and
Officers 1010 $ - -$
Insurance-Fidelity Bond or
Equivalent 1011 500.00$ $ - 500.00$
Other Admin $ 500.00 99,845.00$ 100,345.00$
TOTAL ADMINISTRATIVE
EXPENSES 45,554.00$ 27,637.00$ -$ 759,298.00$ 832,489.00$
% Administrative Cost 5%
PROGRAM PERSONNEL
Salaries 2001 400,360.00$ 218,561.00$ 10,727.00$ 266,623.00$ 896,271.00$
FICA 2002 30,627.00$ 16,720.00$ 821.00$ 21,408.00$ 69,576.00$
Life/Disability Insurance 2003 595.00$ 519.00$ 25.00$ 226.00$ 1,365.00$
Health/Dental Insurance 2004 60,799.00$ 14,521.00$ 1,777.00$ 84,670.00$ 161,767.00$
Unemployment-State 2005 8,963.00$ 8,963.00$
Worker's Compensation 2006 17,925.00$ 17,925.00$
Retirement 12,011.00$ 6,557.00$ 322.00$ 7,999.00$ 26,889.00$
SUPPLIES AND SERVICES
Office/Medical Supplies 3001
Office Equipment Rental 3002
Postage 3003
Printing 3004
MISCELLANEOUS
Contract Labor-Nutritionist 4001 6,000.00$ 6,000.00$
Other Supportive Services 4002 107,460.00$ 2,000.00$ 47,993.00$ 157,453.00$
FACILITY AND UTILITIES
Telephone 5001 -$
Electric 5002 -$
Gas 5003 -$
Water and Wastewater 5004 -$
Solid Waste Disposal 5005 -$
Rent (City needs copy of lease
before expenses can be
reimbursed)5006
Custodial Services 5007 -$
Maintenance/Repairs 5008 -$
Building Security 5009 -$
EXHIBIT "B" - BUDGET
ADMINISTRATIVE
SUPPORTIVE SERVICES
HOPWA PSA CONTRACT 2021 - EXHIBIT "B" - BUDGET
Page 2
LEGAL, FINANCIAL AND
INSURANCE
Professional Liability/Business
Auto 6001
TOTAL SUPPORTIVE
SERVICE EXPENSES 504,392.00$ 370,338.00$ 15,672.00$ 455,807.00$ 1,346,209.00$
Short-term Rent Assistance 7001
Short-term Mortgage Assistance 7002
Short-term Utilities Assistance 7003
Total Direct Assistance-STRMU
Tenant Based Rental Assistance
(TBRA)8001 114,000.00$ 150,000.00$ 168,185.00$ 215,372.00$ 647,557.00$
Total Direct Assistance-TBRA 114,000.00$ 150,000.00$ 168,185.00$ 215,372.00$ 647,557.00$
PERSONNEL
Salaries 9001 132,083.00$ 15,745.00$ 4,576.00$ 70,537.00$ 222,941.00$
FICA 9002 10,104.00$ 1,205.00$ 350.00$ 5,396.00$ 17,055.00$
Life/Disability Insurance 9003 273.00$ 10.00$ 10.00$ 162.00$ 455.00$
Health/Dental Insurance 9004 35,397.00$ 1,007.00$ 612.00$ 25,975.00$ 62,991.00$
Retirement 3,962.00$ 472.00$ 137.00$ 2,116.00$ 6,687.00$
Unemployment-State 9005 2,388.00$ 2,388.00$
Worker's Compensation 9006 4,777.00$ 4,777.00$
Insurance-Commercial Property
and Professional Liability 9007 -$
TOTAL FACILITY BASED
OPERATION EXPENSES 181,819.00$ 18,439.00$ 5,685.00$ 111,351.00$ 317,294.00$
BUDGET TOTAL 845,765.00$ 566,414.00$ 189,542.00$ 1,541,828.00$ 3,143,549.00$
FUNDING A: Tarrrant County HIV Adminstrative Agency - Ryan White A, B, State Services, HOPWA
FUNDING B: Tarrant County Community Development CoC - Grace Village and TBLA
FUNDING C:Fund Raising and Development/CARES Act Funding
FACILITY BASED OPERATIONS
DIRECT ASSISTANCE-STRMU
DIRECT ASSISTANCE-TBRA
HOPWA PSA CONTRACT 2019-2020 - EXHIBIT "B" - BUDGET
AIDS Outreach Center, Inc.Page 3
Annual Salary
Est. Percent to
Grant
Amount to
Grant
33,097.00$ 10.0%3,310.00$
69,763.00$ 10.0%6,976.00$
150,000.00$ 10.0%15,000.00$
125,034.00$ 10.0%12,503.00$
377,894.00$ 37,789.00$
Percent of
Payroll Amount
Est. Percent to
Grant
Amount to
Grant
FICA 7.65%28,909.00$ 10.0%2,891.00$
Life/Disability Insurance 260.00$ 10.0%26.00$
Health/Dental Insurance 32,134.00$ 10.0%3,214.00$
Unemployment-State -$ -$
Worker's Compensation -$ -$
Retirement 3.00%11,337.00$ 10.0%1,134.00$
TOTAL 72,640.00$ 10.0%7,265.00$
Total Budget
Est. Percent to
Grant
Amount to
Grant
-$ -$
500.00$ 100.0%500.00$
500.00$ 100.0%500.00$
Annual Salary
Est. Percent to
Grant
Amount to
Grant
$ 45,000.00 50.0% $ 22,500.00
$ 45,000.00 35.0% $ 15,750.00
$ 45,000.00 50.0% $ 22,500.00
$ 26,208.00 50.0% $ 13,104.00
Case Worker
Case Worker
Case Worker
Cook
Insurance-Directors and Officers
Insurance-Fidelity Bond or Equivalent
TOTAL
SALARY DETAIL - SUPPORTIVE SERVICES
Position Title
MISCELLANEOUS - ADMINISTRATIVE
Contract Labor-Accounting
Insurance-Commercial Umbrella Liability
Mileage
The following tables were created for the purpose of preparing, negotiating, and determining the cost
reasonableness and cost allocation method used by the Agency for the line item budget represented on
the first page of this EXHIBIT “B” – Budget. The information reflected in the tables is to be
considered part of the terms and conditions of the Contract. Agency must have prior written approval
by the City to make changes to any line item in the Budget as outlined in Section 5.2.2 in the
Contract. The deadline to make changes to EXHIBIT “B” – Budget is June 1, 2022.
TOTAL
FRINGE DETAIL - ADMINISTRATIVE
SALARY DETAIL - ADMINISTRATIVE
Position Title
Vice President/Chief Operations Officer
President/Chief Executive Office
Accounting Assistant
Accounting Manager
HOPWA PSA CONTRACT 2019-2020 - EXHIBIT "B" - BUDGET
AIDS Outreach Center, Inc.Page 4
$ 13,104.00 50.0% $ 6,552.00
$ 49,400.00 50.0% $ 24,700.00
$ 35,000.00 50.0% $ 17,500.00
$ 35,000.00 100.0% $ 35,000.00
$ 48,000.00 50.0% $ 24,000.00
$ 30,878.00 100.0% $ 30,878.00
$ 25,738.00 100.0% $ 25,738.00
$ 21,416.00 100.0% $ 21,416.00
$ 21,416.00 100.0% $ 21,416.00
$ 11,154.00 100.0% $ 11,154.00
$ 16,224.00 100.0% $ 16,224.00
$ 13,728.00 100.0% $ 13,728.00
$ 35,000.00 40.0% $ 14,000.00
$ 88,400.00 50.0% $ 44,200.00
$ 50,000.00 40.0% $ 20,000.00
655,666.00$ 400,360.00$
Percent of
Payroll Amount
Est. Percent to
Grant
Amount to
Grant
FICA 7.65%50,158.00$ 61.1%30,627.00$
Life/Disability Insurance 845.00$ 70.4%595.00$
Health/Dental Insurance 120,239.00$ 50.6%60,799.00$
Unemployment-State
Worker's Compensation
Retirement 3.00%19,670.00$ 61.1%12,011.00$
TOTAL 190,912.00$ 54.5%104,032.00$
Total Budget
Est. Percent to
Grant
Amount to
Grant
-$
Total Budget
Est. Percent to
Grant
Amount to
Grant
Life Skills Enrichment Specialist - FT
Life Skills Enrichment Specialist - FT
Life Skills Enrichment Specialist - FT
Life Skills Enrichment Specialist - PRN
Life Skills Enrichment Coordinator
LCDC Case Manager
Cook
Food Service Manager
Head Cook
Intake Coordinator
MISCELLANEOUS - SUPPORTIVE SERVICES
Contract Labor-Nutritionist
Food Supplies
TOTAL
FACILITY AND UTILITIES - SUPPORTIVE SERVICES
TOTAL
Office/Medical Supplies
Office Equipment Rental
Postage
Printing
SUPPLIES AND SERVICES - SUPPORTIVE SERVICES
Life Skills Enrichment Specialist - PT
Life Skills Enrichment Specialist -PT
Resident Services Manager
FRINGE DETAIL - SUPPORTIVE SERVICES
TOTAL
Patient Navigator/Case Worker
Program Director
HOPWA PSA CONTRACT 2019-2020 - EXHIBIT "B" - BUDGET
AIDS Outreach Center, Inc.Page 5
Total Budget
Est. Percent to
Grant
Amount to
Grant
LEGAL, FINANCIAL AND INSURANCE - SUPPORTIVE SERVICES
Maintenance/Repairs
Building Security
TOTAL
Custodial Services
Solid Waste Disposal
Rent (City needs copy of lease before
Utilities (Electric, Gas, water, etc)
Electric
Gas
Water and Wastewater
HOPWA PSA CONTRACT 2019-2020 - EXHIBIT "B" - BUDGET
AIDS Outreach Center, Inc.Page 6
Total Budget
Est. Percent to
Grant
Amount to
Grant
Total Budget
Est. Percent to
Grant
Amount to
Grant
$ - #DIV/0! $ -
$ - #DIV/0! $ -
$ - #DIV/0! $ -
-$ #DIV/0!-$
Total Budget
Est. Percent to
Grant
Amount to
Grant
114,000.00$ 114,000.00$
114,000.00$ 114,000.00$
Annual Salary
Est. Percent to
Grant
Amount to
Grant
60,060.00$ 50.0%30,030.00$
47,133.00$ 50.0%23,567.00$
35,000.00$ 100.0%35,000.00$
32,254.00$ 100.0%32,254.00$
-$ 50.0%-$
22,464.00$ 50.0%11,232.00$
196,911.00$ 132,083.00$
Percent of
Payroll Amount
Est. Percent to
Grant
Amount to
Grant
FICA 7.65%15,064.00$ 67.1%10,104.00$
Life/Disability Insurance 390.00$ 70.0%273.00$
Health/Dental Insurance 52,279.00$ 67.7%35,397.00$
Unemployment-State
Worker's Compensation
Retirement 3%5,907.00$ 67.1%3,962.00$
TOTAL 73,640.00$ 49,736.00$
Position Title
Facilities Manager
Leasing Manager
Maintenance Technician
SALARY DETAIL - FACILITY BASED OPERATIONS
Tenant Based Rental Assistance
TOTAL
DIRECT ASSISTANCE - TBRA
TOTAL
Short Term Utilities Assistance
Maintenance Technician
TOTAL
FRINGE DETAIL - FACILITY BASED OPERATIONS
MISCELLANEOUS - FACILITY BASED OPERATIONS
Maintenance Assistant
Office Assistant
Short-Term Rent Assistance
Short Term Mortgage Assistance
Professional Liability/Business Auto
TOTAL
DIRECT ASSISTANCE - STRMU
HOPWA PSA CONTRACT 2019-2020 - EXHIBIT "B" - BUDGET
AIDS Outreach Center, Inc.Page 7
Total Budget
Est. Percent to
Grant
Amount to
Grant
845,765.00$
845,765.00$
-$
Insurance-Commercial Property and
TOTAL
1 HOPWA PSA CONTRACT 2021-2022 – EXHIBIT “C” ―
AUDIT CERTIFICATION
TARRANT COUNTY SAMARITAN HOUSING, INC.
EXHIBIT “C”
AUDIT CERTIFICATION FORM
DocuSign Envelope ID: A4305BCF-F7A8-44BC-B88C-F10FF675399A
2 HOPWA PSA CONTRACT 2021-2022 – EXHIBIT “C” ― AUDIT
CERTIFICATION TARRANT COUNTY SAMARITAN HOUSING, INC.
AUDIT CERTIFICATION FORM AND AUDIT REQUIREMENTS
Agency: TARRANT COUNTY SAMARITAN HOUSING, INC.
Fiscal Year Ending: September 30, 2022
During the fiscal year in which funds will be received, we will exceed the federal expenditure
threshold of $750,000. We will have our Single Audit or Program Specific Audit completed
and will submit the audit report described in 2 CFR Part 200 within 7 months after the end
of the audited fiscal year or 30 days within its completion, whichever is the earlier date.
During the fiscal year in which funds will be received, we will not exceed the $750,000 federal
expenditure threshold required for a Single Audit or a Program Specific Audit to be performed
this fiscal year. (Fill out schedule below)
Federal Expenditure Disclosure
MUST be filled out if Single Audit or Program Audit is NOT required.
Federal Grantor Pass Through
Grantor
Program Name &
CFDA Number
Contract
Number Expenditures
Total Federal Expenditures for this Fiscal Year:
_________________________________ __________________________
Signatory and Title Date
Failure to submit this or a similar statement or failure to submit a completed single audit package
as described in the federally required audit requirements described in 2 CFR Part 200, as
applicable, by the required due date may result in suspension of funding and may affect eligibility
for future funding. Notwithstanding the above, this certification acknowledges the agency’s
commitment to meet all other financial reporting, financial statements, and other audit
requirements as may be set forth in the Contract.
DocuSign Envelope ID: A4305BCF-F7A8-44BC-B88C-F10FF675399A
10/14/2021
1
Exhibit "D" -- Reporting Forms
[See attached]
2
Agency:
Address:
City, State, Zip:
Program:
Period of Service:
Tax ID No.
P.O. No.
FID No.
This Invoice Cumulative to Date
HOPWA-Admin
Administrative
Program Amount
Attachment I
INVOICE
Tarrant County Samaritan Housing, Inc.
929 Hemphill St.
Fort Worth, TX 76104
3
Agency:
Address:
City, State, Zip:
Program:
Period of Service:
Tax ID No.
P.O. No.
FID No.
This Invoice Cumulative to Date
HOPWA-Supp. Serv.
Supportive Services
Program Amount
Attachment I
INVOICE
Tarrant County Samaritan Housing, Inc.
929 Hemphill St.
Fort Worth, TX 76104
4
Agency:
Address:
City, State, Zip:
Program:
Period of Service:
Tax ID No.
P.O. No.
FID No.
This Invoice Cumulative to Date
HOPWA-Operations
Facility Based Operations
Program Amount
Attachment I
INVOICE
Tarrant County Samaritan Housing, Inc.
929 Hemphill St.
Fort Worth, TX 76104
Agency:
Address:
City, State, Zip:
Program:
Period of Service:
Tax ID No.
P.O. No.
FID No.
This Invoice Cumulative to Date
HOPWA-TBRA
Program Amount
Tenant Based Rental Assistance
Attachment I
INVOICE
Tarrant County Samaritan Housing, Inc.
929 Hemphill St.
Fort Worth, TX 76104
6
Agency:
Program:
Only highlighted codes can be reimbursed
Please group like account codes.
Line
No.Check No.Date Payee Description/Job Title*
Account
Code (See
Key to Right)Amount
Expense Line Item
Account
1
2 Salaries 1001
3 FICA 1002
4 Life/Disability Insurance 1003
5 Health/Dental Insurance 1004
6 Unemployment-State 1005
7 Worker’s Compensation 1006
8 Contract Labor 1007
9 Other (Audit Fees)1008
10 Insurance-Commercial Liab.1009
11 Insurance-Directors & Officers 1010
12 Insurance-Fidelity Bond or Eq.1011
13
14
15 Salaries 2001
16 FICA 2002
17 Life/Disability Insurance 2003
18 Health/Dental Insurance 2004
19 Unemployment-State 2005
20 Worker’s Compensation 2006
21
22 Office/Medical Supplies 3001
23 Office Equipment Rental 3002
24 Postage 3003
25 Printing 3004
26
27 Contract Labor 4001
28 Food Supplies 4002
29 Client Transportation 4003
30
31 Telephone 5001
32 Electric 5002
33 Gas 5003
34 Water and Wastewater 5004
35 Solid Waste Disposal 5005
36 Rent 5006
37 Custodial Services 5007
38 Maintenance/Repairs 5008
39 Building Security 5009
40
41 Directors and Officers Insurance 6001
42
43 Short-term Rent Assistance 7001
44 Short-term Mortgage Assistance 7002
45 Short-term Utilities Assistance 7003
46
47 Tenant Based Rental Assistance 8001
48
49 Salaries 9001
50 FICA 9002
51 Life/Disability Insurance 9003
52 Health/Dental Insurance 9004
53 Unemployment-State 9005
54 Worker’s Compensation 9006
55 Ins.-Comm. Prop. and Prof. Liab.9007
56 Telephone 9008
57 Electric 9009
58 Maintenance/Repairs 9010
59 Cleaning Supplies 9011
60
Total $0.00
*For Salaries, state employee's title under Description/Job Title. Rent must identify tenant
ADMINISTRATIVE
SUPPORTIVE SERVICES
DIRECT ASSISTANCE-STRMU
DIRECT ASSISTANCE-TBRA
PROGRAM PERSONNEL
SUPPLIES AND SERVICES
MISCELLANEOUS
FACILITY AND UTILITIES
LEGAL, FINANCIAL AND INSURANCE
FACILITY BASED OPERATIONS
Administrative
ATTACHMENT II
City of Fort Worth
Neighborhood Services Department
Expenditure Worksheet
Tarrant County Samaritan House, Inc.
7
Agency:
Program:
Only highlighted codes can be reimbursed
Please group like account codes.
Line
No.Check No.Date Payee Description/Job Title*
Account
Code (See
Key to Right)Amount
Expense Line Item
Account
1
2 Salaries 1001
3 FICA 1002
4 Life/Disability Insurance 1003
5 Health/Dental Insurance 1004
6 Unemployment-State 1005
7 Worker’s Compensation 1006
8 Contract Labor 1007
9 Other (Audit Fees)1008
10 Insurance-Commercial Liab.1009
11 Insurance-Directors & Officers 1010
12 Insurance-Fidelity Bond or Eq.1011
13
14
15 Salaries 2001
16 FICA 2002
17 Life/Disability Insurance 2003
18 Health/Dental Insurance 2004
19 Unemployment-State 2005
20 Worker’s Compensation 2006
21
22 Office/Medical Supplies 3001
23 Office Equipment Rental 3002
24 Postage 3003
25 Printing 3004
26
27 Contract Labor 4001
28 Food Supplies 4002
29 Client Transportation 4003
30
31 Telephone 5001
32 Electric 5002
33 Gas 5003
34 Water and Wastewater 5004
35 Solid Waste Disposal 5005
36 Rent 5006
37 Custodial Services 5007
38 Maintenance/Repairs 5008
39 Building Security 5009
40
41 Directors and Officers Insurance 6001
42
43 Short-term Rent Assistance 7001
44 Short-term Rent Assistance 7002
45 Short-term Mortgage Assistance 7003
46
47 Tenant Based Rental Assistance 8001
48
49 Salaries 9001
50 FICA 9002
51 Life/Disability Insurance 9003
52 Health/Dental Insurance 9004
53 Unemployment-State 9005
54 Worker’s Compensation 9006
55 Ins.-Comm. Prop. and Prof. Liab.9007
56 Telephone 9008
57 Electric 9009
58 Maintenance/Repairs 9010
59 Cleaning Supplies 9011
60
Total $0.00
FACILITY AND UTILITIES
ATTACHMENT II
City of Fort Worth
Neighborhood Services Department
Expenditure Worksheet
Tarrant County Samaritan House, Inc.
Supportive Services
ADMINISTRATIVE
SUPPORTIVE SERVICES
PROGRAM PERSONNEL
SUPPLIES AND SERVICES
MISCELLANEOUS
LEGAL, FINANCIAL AND INSURANCE
DIRECT ASSISTANCE-STRMU
DIRECT ASSISTANCE-TBRA
FACILITY BASED OPERATIONS
*For Salaries, state employee's title under Description/Job Title. Rent must identify tenant
8
Agency:
Program:
Only highlighted codes can be reimbursed
Please group like account codes.
Line
No.Check No.Date Payee Description/Job Title*
Account
Code (See
Key to Right)Amount
Expense Line Item
Account
1
2 Salaries 1001
3 FICA 1002
4 Life/Disability Insurance 1003
5 Health/Dental Insurance 1004
6 Unemployment-State 1005
7 Worker’s Compensation 1006
8 Contract Labor 1007
9 Other (Audit Fees)1008
10 Insurance-Commercial Liab.1009
11 Insurance-Directors & Officers 1010
12 Insurance-Fidelity Bond or Eq.1011
13
14
15 Salaries 2001
16 FICA 2002
17 Life/Disability Insurance 2003
18 Health/Dental Insurance 2004
19 Unemployment-State 2005
20 Worker’s Compensation 2006
21
22 Office/Medical Supplies 3001
23 Office Equipment Rental 3002
24 Postage 3003
25 Printing 3004
26
27 Contract Labor 4001
28 Food Supplies 4002
29 Client Transportation 4003
30
31 Telephone 5001
32 Electric 5002
33 Gas 5003
34 Water and Wastewater 5004
35 Solid Waste Disposal 5005
36 Rent 5006
37 Custodial Services 5007
38 Maintenance/Repairs 5008
39 Building Security 5009
40
41 Directors and Officers Insurance 6001
42
43 Short-term Rent Assistance 7001
44 Short-term Mortgage Assistance 7002
45 Short-term Utilities Assistance 7003
46
47 Tenant Based Rental Assistance 8001
48
49 Salaries 9001
50 FICA 9002
51 Life/Disability Insurance 9003
52 Health/Dental Insurance 9004
53 Unemployment-State 9005
54 Worker’s Compensation 9006
55 Ins.-Comm. Prop. and Prof. Liab.9007
56 Telephone 9008
57 Electric 9009
58 Maintenance/Repairs 9010
59 Cleaning Supplies 9011
60
Total $0.00
FACILITY AND UTILITIES
ATTACHMENT II
City of Fort Worth
Neighborhood Services Department
Expenditure Worksheet
Tarrant County Samaritan House, Inc.
Facility Based Operations
ADMINISTRATIVE
SUPPORTIVE SERVICES
PROGRAM PERSONNEL
SUPPLIES AND SERVICES
MISCELLANEOUS
LEGAL, FINANCIAL AND INSURANCE
DIRECT ASSISTANCE-STRMU
DIRECT ASSISTANCE-TBRA
FACILITY BASED OPERATIONS
*For Salaries, state employee's title under Description/Job Title. Rent must identify tenant
9
Agency:
Program:
Only highlighted codes can be reimbursed
Please group like account codes.
Line
No.Check No.Date Payee Description/Job Title*
Account
Code (See
Key to Right)Amount
Expense Line Item
Account
1
2 Salaries 1001
3 FICA 1002
4 Life/Disability Insurance 1003
5 Health/Dental Insurance 1004
6 Unemployment-State 1005
7 Worker’s Compensation 1006
8 Contract Labor 1007
9 Other (Audit Fees)1008
10 Insurance-Commercial Liab.1009
11 Insurance-Directors & Officers 1010
12 Insurance-Fidelity Bond or Eq.1011
13
14
15 Salaries 2001
16 FICA 2002
17 Life/Disability Insurance 2003
18 Health/Dental Insurance 2004
19 Unemployment-State 2005
20 Worker’s Compensation 2006
21
22 Office/Medical Supplies 3001
23 Office Equipment Rental 3002
24 Postage 3003
25 Printing 3004
26
27 Contract Labor 4001
28 Food Supplies 4002
29
30 Telephone 5001
31 Electric 5002
32 Gas 5003
33 Water and Wastewater 5004
34 Solid Waste Disposal 5005
35 Rent 5006
36 Custodial Services 5007
37 Maintenance/Repairs 5008
38 Building Security 5009
39
40 Directors and Officers Insurance 6001
41
42 Short-term Rent Assistance 7001
43 Short-term Mortgage Assistance 7002
44 Short-term Utilities Assistance 7003
45
46 Tenant Based Rental Assistance 8001
47
48 Salaries 9001
49 FICA 9002
50 Life/Disability Insurance 9003
51 Health/Dental Insurance 9004
52 Unemployment-State 9005
53 Worker’s Compensation 9006
54 Ins.-Comm. Prop. and Prof. Liab.9007
55 Telephone 9008
56 Electric 9009
57 Maintenance/Repairs 9010
58 Cleaning Supplies 9011
59
60
Total $0.00
LEGAL, FINANCIAL AND INSURANCE
DIRECT ASSISTANCE-STRMU
DIRECT ASSISTANCE-TBRA
FACILITY BASED OPERATIONS
*For Salaries, state employee's title under Description/Job Title. Rent must identify tenant
FACILITY AND UTILITIES
ATTACHMENT II
City of Fort Worth
Neighborhood Services Department
Expenditure Worksheet
Tarrant County Samaritan House, Inc.
Tenant Based Rent Assistance
ADMINISTRATIVE
SUPPORTIVE SERVICES
PROGRAM PERSONNEL
SUPPLIES AND SERVICES
MISCELLANEOUS
Agency:
Program:
Month:
0
14
0.00%
2 3 4 8 11
<30%AMI 30%-50%
AMI
51-80%
AMI
1<$17,000 1<$28,300 1<$45,300
2<$19,400 2<$32,350 2<$51,750
3<$21,850 3<$36,400 3<$58,200
4<$24,250 4<$40,400 4<$64,650
5<$26,200 5<$43,650 5<$69,850
6<$28,150 6<$46,900 6<$75,000
7<$30,100 7<$50,100 7<$80,200
8<$32,050 8<$53,350 8<$85,350 YES NO
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
*Proposed Client Goal Per Contract
ATTACHMENT III
CLIENT DATA REPORT
HOPWA Project Sponsor Activity - TBRA
Tarrant County Samaritan Housing
Tenant Based Rental Assistance (TBRA)
Instructions:This report is meant to list all unduplicated clients served during the Contract term (October 1, 2020 to September 30, 2021). Each month, please report the information of clients not previously reported. You are required to attach eligibility verification documentation for each new client. New unduplicated clients should
be listed below any previously reported ones so that this sheet will act as a rolling tally. Please only list clients one time during the first month that they receive service. Clients that continue to receive Program services for multiple months only need to be listed one time. Put an "X" in each appropriate box regarding the
client's sex, ethnicity, race, etc. Please note that reimbursement for salaries will require that the agency report to the City all the clients that were served by that particular staff person in that program. Information for each client listed below must have the demographic information reflected in columns 1 thru 12.
Undup Clts for CURRENT MONTH * Please highlight new clients for the month.
CUMULATIVE Unduplicated Clients
% of Milestone Met
*Do not revise the client goal unless the contract is amended, accordingly.
1 5 6 9 10 12
DATE
CLIENT
RECEIVED
SERVICE
CLIENT NUMBER STREET ADDRESS
(Client Address)
AGE
SEX
(Indicate One)
ETHNICITY
(Indicate One)
7
DID
HOUSEHOLD
OBTAIN AN
INCOME-
PRODUCING
JOB?
BLACK OR
AFRICAN
AMERICAN
NATIVE
HAWAIIAN
OR OTHER
PACIFIC
ISLANDER WHITE
AMERICAN
INDIAN OR
ALASKAN
NATIVE
AND WHITE
RACE
(Indicate One)
HH
SIZE
HH INCOME
(Only choose 1 of the 3 columns)
FHOH
(Indicate
One)
PERFORMANCE
OUTCOMES
NOASIAN
ASIAN AND
WHITE
BLACK OR
AFRICAN
AMERICAN
AND WHITE
AMERICAN
INDIAN OR
ALASKA
NATIVE
AND BLACK
OR
AFRICAN
AMERICAN
OTHER
MULTIPLE
RACE
COMBINATI
ONS*YESMALEFEMALEHISPANIC
NON-
HISPANIC
AMERICAN
INDIAN OR
ALASKAN
NATIVE
Tarrant County Samaritan Housing, Inc. Page 1
EXHIBIT “E”
INCOME CERTIFICATION FORMS
Tarrant County Samaritan Housing, Inc. Page 2
City of Fort Worth
CERTIFICATION OF INCOME STATEMENT
Applicant Name: ____________________________________
Current Address: ____________________________________Phone #:
City and Zip:
Household Members and Income
(including applicant)
Last Name First Name Age Monthly
Income $$
Source of Income
TOTAL NUMBER OF FAMILY MEMBERS (Include Yourself, Spouse, Children, etc.)
Total Gross Annual Household Income: ________
PERSONAL INFORMATION: (Check one in each item. This Information is Required for Federal Reporting Purposes)
a. MALE b. WHITE BLACK/AFRICAN AMERICAN BLACK/AFRICAN AMERICAN & WHITE
FEMALE AMERICAN INDIAN/ALASKAN NATIVE ASIAN
AMERICAN INDIAN/ALASKAN NATIVE & WHITE ASIAN & WHITE
NATIVE HAWAIIAN/OTHER PACIFIC ISLANDER BALANCE/OTHER
AMERICAN INDIAN/ALASKAN NATIVE & BLACK/AFRICAN AMERICAN
c. ETHNICITY d. DISABLED e. IS HEAD OF HOUSEHOLD FEMALE?
HISPANIC YES YES
NON-HISPANIC NO NO
Certification: I certify that the information I am providing is true and could be subject to verification at any
time by a third party. I also acknowledge that the provision of false information could leave me subject to the
penalties of Federal, State and local law.
__________________ _____________
Signature of Applicant Date
WARNING: TITLE 18, SECTION 1001 OF THE U.S. CODE STATES THAT A PERSON IS GUILTY OF A FELONY
FOR KNOWINGLY AND WILLINGLY MAKING FALSE OR FRAUDULENT STATEMENTS TO ANY DEPARTMENT OF
THE UNITED STATES GOVERNMENT.
-----------------For use by Agency staff only-----------------
Household Size: Gross Annual Income:
Applicable Income Limit: Is Applicant Eligible?
Check if Applicant refused to provide demographic information: Õ
Staff Assessment of Demographics:____________________________________________________________
Person Making Determination: Date:
NOTE: Address, income amounts and sources for ALL household members are required.
Tarrant County Samaritan Housing, Inc. Page 3
Ciudad de Fort Worth
CERTIFICACIÓN DE DECLARACIÓN DE INGRESOS
Nombre del Solicitante:
Dirección de Actualidad: Teléfono:
Ciudad y Código Postal:
Miembros Del Hogar e Ingresos
(Incluyendo el/la Solicitante)
Apellido Nombre Edad Ingreso
Mensual
Origen de Ingresos
* TOTAL NÚMERO DE MIEMBROS DEL HOGAR (Inclúyase Usted.)
Total Anual de Ingresos del hogar:
**INFORMACIÓN PERSONAL: (Seleccione uno en cada artículo. Esta información es requerida por el Gobierno federal.)
a. MASCULINO b. BLANCO NEGRO/AFRICANO AMERICANO NEGRO/AFRICANO AMERICANO & BLANCO
FEMININO INDIO AMERICANO/NATIVO DE ALASKA ASIATICO
INDIO AMERICANO/NATIVO DE ALASKA & BLANCO ASIATICO & BLANCO
NATIVO HAWAIANO/OTRO DE LAS ISLAS PACIFICAS BALANCE/OTRO
INDIO AMERICANO / NATIVO DE ALASKA & NEGRO/AFRICANO AMERICANO
c. ETHNICIDAD d. INCAPACITADO e. ¿ES LA CABEZA DEL HOGAR MUJER?
HISPANO SI SI
NO-HISPANO NO NO
Certificación: Yo certifico que la información que yo estoy proporcionando es verdadera y puedo ser sujeto a
verificación a cualquiera hora por tercera parte. Yo también reconozco que la provisión de información falsa
puede dejarme sujeto a penalidades Federales, Estatales, y a ley local.
Firma del Solicitante Fecha
ADVERTENCIA: TITULO 18, SECCIÓN 1001 DEL CÓDIGO DE LOS ESTADOS UNIDOS INDICA QUE UNA
PERSONA ES CULPABLE DE UN DELITO POR SABER Y VOLUNTARIAMENTE HACER DECLARACIONES FALSOS O
FRAUDULENTAS A CUALQUIER DEPARTAMENTO DE GOBIERNO DE LOS ESTADOS UNIDOS.
-----------------Para use de empleados de la agencia-----------------
# De Miembros de Familia: Ingreso Anual:
Límite de Ingreso: ¿Es solicitante elegible? :
Compruebe si el solicitante se negó a dar su información personal: ____________________________
Evaluación del empleado sobre información personal:____________________________________________
Persona haciendo la determinación: Fecha:
Note: La dirección de la casa y los ingresos (y sus orígenes) para todos los miembros del hogar, es requerida.
HOPWA PSA CONTRACT 2021-2022 -- EXHIBIT “F” -- STANDARDS OF DOCUMENTATION Page 1
Tarrant County Samaritan Housing, Inc.
EXHIBIT “F”
STANDARDS OF DOCUMENTATION
HOPWA PSA CONTRACT 2020-2021 Exhibit "F" -- STANDARDS FOR COMPLETE DOCUMENTATION 1InvoiceProof of Payment*TimesheetContract/AgreementSAM.gov SearchLeaseExplanation of how expense is related to ProgramNotes/Other
Salaries X X *
If an employee works on both a HOPWA eligible and non-HOPWA eligible program(s), the City will only reimburse for a reasonable
portion of the employee's salary. Prior to the execution of the HOPWA Contract, the Agency will priovide the City with a written
statement on how each employee's time will be allocated. If an employee works 100% of their time directly with the HOPWA-funded
Program, then 100% of the employee's salary may be eligible for reimbursement. Agency must submit a written statement that 100% of
the employee's time is spent working directly with the HOPWA-funded Program. Statements must be signed by a person authorized to
sign on behalf of the Agency and will be submitted with the October invoice.
Reimbursement requests must include a timesheet and work log that reflects the hours worked by the employee(s) working directly on
the HOPWA-funded Program. For employees who are paid with multiple funding sources, timesheets must reflect all funding sources.
If separate timesheets are kept for each funding source, all such timesheets must be submitted to City. Timesheets must be signed by
employee and supervisor. Agency must show a calculation and documentation of how the employee's salary was calculated and
invoiced to City.
*If employees are paid by direct deposit rather than check, then the agency must submit both the direct deposit payment company's
report (such as an ADT report) and a bank statement or check showing payment to the direct deposit company.
FICA/Medicare X X X
Life Insurance X X X
Health
Insurance X X X
Disability
Insurance X X X
Unemployment
Insurance X X X
Retirement X X X
If the City pays gross salary, this is already included. If the City pays the employer portion, the Agency must provide proof that the
employee is enrolled in the benefit plan, must show a calculation and documentation of how the invoiced amount was calculated, and
must provide documentation showing payment. Invoice and proof of payment are only required with the first reimbursement request and
at any time there are changes to amounts, enrollments, disenrollments, etc.
Office Supplies X X X
Office
Equipment
Rental
X X X X X
Postage X X X
Printing X X X
Construction &
Building
Materials
X X X X This category is only available for the REACH Program and Habitat for Humanity.
Sport and
Recreation
Equipment
X X X
Cleaning
Supplies X X X
Teaching Aids X X X
Craft Supplies X X X
Food Supplies X X X This category is only available to the Program provided by Meals on Wheels.
Telephone X X
Gas X X
Water/Wastew
ater X X
Electric X X
Solid Waste X X
2021-2022 Documentation Standards for
HOPWA Public Service Contract Expenses
Budget Line
Items
Employee Salaries and Benefits - City will only reimburse a percentage of any employee's salary and benefits who work directly with the HOPWA-funded Program.
Percentages will be cost allocated and determined prior to the execution of the HOPWA Contract. Agencies requesting the reimbursement of 100% of any Agency employee
will require prior City approval. Agencies must show calculation on how the HOPWA portion of employee salaries and benefits were calculated consistently with the HOPWA
Contract.
If the City pays gross salary, this is already included. If the City pays the employer portion, the Agency must provide proof that the
employee is enrolled in the benefit plan, must show a calculation and documentation of how the invoiced amount was calculated, and
must provide documentation showing payment. Invoice and proof of payment are only required with the first reimbursement request and
at any time there are changes to amounts, enrollments, disenrollments, etc.
Materials, Equipment, Goods and Supplies - City will only reimburse for the cost allocated percent or amount spent in support of the HOPWA-funded Program. Agencies
requesting reimbursement for these items will require prior City approval. Agencies must show calculation on how the HOPWA portion of these expenses were calculated
consistently with the HOPWA Contract.
Rent, Utilities and Maintenance - City will only pay for a portion of these expenses. The portion of these expenses will be determined by the square footage attributable to
the HOPWA-funded Program and shall be cost-allocated in accordance with the amount of space used for the HOPWA-funded Program. These expenses may only be in
support of the HOPWA-funded Program. The items listed below require prior City approval and the Agency is required to identify any funding source that pays for the
portion of the expenses that is not paid with HOPWA funds. Agencies must show calculation on how the HOPWA portion of these expenses were calculated consistently
with the HOPWA Contract.
HOPWA PSA CONTRACT 2020-2021 Exhibit "F" -- STANDARDS FOR COMPLETE DOCUMENTATION 1
Facility
Maintenance
and Repairs
X X X X This item requires approval by the City prior to the execution of the HOPWA Contract. Repairs may be categorized as major/minor
rehabilitation projects and must be approved through the full HUD Environmetal Review.
Rent X X X City will pay for a portion of the rent for the Program facility so long as its in proportion to the square footage attributable to the HOPWA-
funded program.
Contract Labor X X X X X
This item requires prior approval by the City. Prior to the execution of the HOPWA Contract, the Agency must submit a written
statement that lists the contract labor services to be used during the Contract term. Agency will submit a memo related to the
procurement of such services and will forward any information pertaining to the procurement process to City. This requirement applies
to, but is not limited to, services retained for security services, legal, accounting, transportation providers, educational facilitators,
custodial services, etc. Agencies may not use the contract services of any City of Fort Worth Department.
City-required
Insurance X X City will only pay for a percentage of the City-required insurance so long as it's in proportion to the square footage attributable to the
HOPWA-funded program.
Childcare
Scholarships X X
City requires that the agency submit its fee schedule or formula on how the Agency calculates the childcare scholarship amount. The
fee schedule/formula should demonstrate a breakout of income levels, and for each income level the schedule should demonstrate
which portion of the expense is to be paid by the family and which portion of the expense is to be reimbursed by the City. A fee
schedule/formula must be submitted to the City prior to the first payment. Agency must submit documentation supporting that the client
is income eligible and that the household is being charged in conformance with the fee schedule. If the fee schedule/formula changes at
any time during the contract term, the Agency must immediately notify City on the date the new fee schedule/formula takes into effect.
"$0" Income
Certifications
Agecies that are required to verify and provide proof of household income to determine eligibility, must require that anyone who is over
the age of 18, living in the housohold, submit a $0 Income Certification.
Audit Services X X X X
If an audit is required because federal funds exceed $750,000, then the cost should be split evenly by all grant funding sources. Agency
must show calculation on how the HOPWA portion of the accounting services were calculated. For example, if the HOPWA grant is
10% of your Agency's budget, then invoice shall not exceed 10% of the overall cost. Agency must show a calculation and
documentation of how the invoiced amount was calculated, and must provide documentation showing payment.
Final as of 09/19/2018 SF
Miscellaneous
*Proof of payment effective October 1, 2013:Payments or Expenses must be documented in the following manner:
A) Image of the check AND bank statement showing the check cleared the bank; OR,
B) Image of the cancelled check (ex. At end of bank statement); OR,
C) Payroll Check Stub, "Advice", or Statement AND Bank Statement indicating payroll; OR,
D) For wire or e-transfers: Reciept or statement from payee/vendor OR bank statement.
HOPWA PSA CONTRACT 2021-2022 -- EXHIBIT “G” -- SECTION 3 REPORTING FORMS Page 1
Tarrant County Samaritan Housing, Inc.
EXHIBIT “G”
SECTION 3 REPORTING FORMS
NOT APPLICABLE
HOPWA PSA CONTRACT 2021-2022 -- EXHIBIT “H” – OVERVIEW REPORT Page 1
Tarrant County Samaritan Housing, Inc.
EXHIBIT “H”
OVERVIEW REPORT
______________________________________________________________________________
Previous editions are obsolete form HUD-40110-D (Expiration Date: 10/31/2017
Housing Opportunities for Persons with AIDS
(HOPWA) Program
Consolidated Annual Performance and
Evaluation Report (CAPER)
Measuring Performance Outcomes
Revised 1/22/15
OMB Number 2506-0133 (Expiration Date: 12/31/2017)
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 Page i form HUD-40110-D (Expiration Date: 10/31/2017)
Overview. The Consolidated Annual Performance and Evaluation Report
(CAPER) provides annual performance reporting on client outputs and
outcomes that enables an assessment of grantee performance in achieving the
housing stability outcome measure. The CAPER, in conjunction with the
Integrated Disbursement Information System (IDIS), fulfills statutory and
regulatory program reporting requirements and provides the grantee and
HUD with the necessary information to assess the overall program
performance and accomplishments against planned goals and objectives.
HOPWA formula grantees are required to submit a CAPER, and complete
annual performance information for all activities undertaken during each
program year in the IDIS, demonstrating coordination with other
Consolidated Plan resources. HUD uses the CAPER and IDIS data to obtain
essential information on grant activities, project sponsors, Subrecipient
organizations, housing sites, units and households, and beneficiaries (which
includes racial and ethnic data on program participants). The Consolidated
Plan Management Process tool (CPMP) provides an optional tool to integrate
the reporting of HOPWA specific activities with other planning and reporting
on Consolidated Plan activities.
Table of Contents
PART 1: Grantee Executive Summary
1. Grantee Information
2. Project Sponsor Information
3. Administrative Subrecipient Information
4. Program Subrecipient Information
5. Grantee Narrative and Performance Assessment
a. Grantee and Community Overview
b. Annual Performance under the Action Plan
c. Barriers or Trends Overview
d. Assessment of Unmet Housing Needs
PART 2: Sources of Leveraging and Program Income
1. Sources of Leveraging
2. Program Income and Resident Rent Payments
PART 3: Accomplishment Data: Planned Goals and Actual Outputs
PART 4: Summary of Performance Outcomes
1. Housing Stability: Permanent Housing and Related Facilities
2. Prevention of Homelessness: Short-Term Housing Payments
3. Access to Care and Support: Housing Subsidy Assistance with
Supportive Services
PART 5: Worksheet - Determining Housing Stability Outcomes
PART 6: Annual Certification of Continued Use for HOPWA Facility-
Based 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: Name, Social Security Number, Date of Birth, Ethnicity and Race,
Gender, Veteran Status, Disabling Conditions, Residence Prior to Program
Entry, Zip Code of Last Permanent Address, Housing Status, Program Entry
Date, Program Exit Date, Personal Identification Number, and Household
Identification Number. These are intended to match the elements under
HMIS. The HOPWA program-level data elements include: Income and
Sources, Non-Cash Benefits, HIV/AIDS Status, Services Provided, 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
Assistance, Housing Relocation & Stabilization Services, Employment,
Education, General Health Status, , Pregnancy Status, Reasons for Leaving,
Veteran’s Information, and Children’s Education. Other HOPWA projects
sponsors may also benefit from collecting these data elements.
Final Assembly of Report. After the entire report is assembled, please
number each page sequentially.
Filing Requirements. Within 90 days of the completion of each program
year, grantees must submit their completed CAPER to the CPD Director in
the grantee’s State or Local HUD Field Office, and to the HOPWA Program
Office: at HOPWA@hud.gov. Electronic submission to HOPWA Program
office is preferred; however, if electronic submission is not possible, hard
copies can be mailed to: Office of HIV/AIDS Housing, Room 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 [1b] in the following manner:
HOPWA Housing Subsidy
Assistance
[1] Outputs:
Number of
Households
1. Tenant-Based Rental Assistance 1
2a.
Permanent Housing Facilities:
Received Operating
Subsidies/Leased units
2b.
Transitional/Short-term
Facilities:
Received Operating Subsidies
3a.
Permanent Housing Facilities:
Capital Development Projects
placed in service during the
operating year
3b.
Transitional/Short-term
Facilities:
Capital Development Projects
placed in service during the
operating year
4. Short-term Rent, Mortgage, and
Utility Assistance 1
5. Adjustment for duplication
(subtract) 1
6.
TOTAL Housing Subsidy
Assistance (Sum of Rows 1-4
minus Row 5) 1
______________________________________________________________________________________
Previous editions are obsolete Page ii form HUD-40110-D (Expiration Date: 10/31/2017)
Administrative Costs: Costs for general management, oversight,
coordination, evaluation, and reporting. By statute, grantee administrative
costs are limited to 3% of total grant award, to be expended over the life of
the grant. Project sponsor administrative costs are limited to 7% of the
portion of the grant amount they receive.
Beneficiary(ies): All members of a household who received HOPWA
assistance during the operating year including the one individual who
qualified the household for HOPWA assistance as well as any other
members of the household (with or without HIV) who benefitted from the
assistance.
Central Contractor Registration (CCR): The primary registrant
database for the U.S. Federal Government. CCR collects, validates, stores,
and disseminates data in support of agency acquisition missions, including
Federal agency contract and assistance awards. Both current and potential
federal government registrants (grantees) are required to register in CCR
in order to be awarded contracts by the federal government. Registrants
must update or renew their registration at least once per year to maintain
an active status. Although recipients of direct federal contracts and grant
awards have been required to be registered with CCR since 2003, this
requirement is now being extended to indirect recipients of federal funds
with the passage of ARRA (American Recovery and Reinvestment Act).
Per ARRA and FFATA (Federal Funding Accountability and
Transparency Act) federal regulations, all grantees and sub-grantees or
subcontractors receiving federal grant awards or contracts must have a
DUNS (Data Universal Numbering System) Number.
Chronically Homeless Person: An individual or family who : (i) is
homeless and lives or resides individual or family who: (i) Is homeless and
lives or resides in a place not meant for human habitation, a safe haven, or
in an emergency shelter; (ii) has been homeless and living or residing in a
place not meant for human habitation, a safe haven, or in an emergency
shelter continuously for at least 1 year or on at least 4 separate occasions in
the last 3 years; and (iii) has an adult head of household (or a minor head
of household if no adult is present in the household) with a diagnosable
substance use disorder, serious mental illness, developmental disability (as
defined in section 102 of the Developmental Disabilities Assistance and
Bill of Rights Act of 2000 (42 U.S.C. 15002)), post traumatic stress
disorder, cognitive impairments resulting from a brain injury, or chronic
physical illness or disability, including the co-occurrence of 2 or more of
those conditions. Additionally, the statutory definition includes as
chronically homeless a person who currently lives or resides in an
institutional care facility, including a jail, substance abuse or mental health
treatment facility, hospital or other similar facility, and has resided there
for fewer than 90 days if such person met the other criteria for homeless
prior to entering that facility. (See 42 U.S.C. 11360(2))This does not
include doubled-up or overcrowding situations.
Disabling Condition: Evidencing a diagnosable substance use disorder,
serious mental illness, developmental disability, chronic physical illness,
or disability, including the co-occurrence of two or more of these
conditions. In addition, a disabling condition may limit an individual’s
ability to work or perform one or more activities of daily living. An
HIV/AIDS diagnosis is considered a disabling condition.
Facility-Based Housing Assistance: All eligible HOPWA Housing
expenditures for or associated with supporting facilities including
community residences, SRO dwellings, short-term facilities, project-based
rental units, master leased units, and other housing facilities approved by
HUD.
Faith-Based Organization: Religious organizations of three types: (1)
congregations; (2) national networks, which include national
denominations, their social service arms (for example, Catholic Charities,
Lutheran Social Services), and networks of related organizations (such as
YMCA and YWCA); and (3) freestanding religious organizations, which
are incorporated separately from congregations and national networks.
Grassroots Organization: An organization headquartered in the local
community where it provides services; has a social services budget of
$300,000 or less annually, and six or fewer full-time equivalent
employees. Local affiliates of national organizations are not considered
“grassroots.”
HOPWA Eligible Individual: The one (1) low-income person with
HIV/AIDS who qualifies a household for HOPWA assistance. This person
may be considered “Head of Household.” When the CAPER asks for
information on eligible individuals, report on this individual person only.
Where there is more than one person with HIV/AIDS in the household, the
additional PWH/A(s), would be considered a beneficiary(s).
HOPWA Housing Information Services: Services dedicated to helping
persons living with HIV/AIDS and their families to identify, locate, and
acquire housing. This may also include fair housing counseling for eligible
persons who may encounter discrimination based on race, color, religion,
sex, age, national origin, familial status, or handicap/disability. .
HOPWA Housing Subsidy Assistance Total: The unduplicated number
of households receiving housing subsidies (TBRA, STRMU, Permanent
Housing Placement services and Master Leasing) and/or residing in units
of facilities dedicated to persons living with HIV/AIDS and their families
and supported with HOPWA funds during the operating year.
Household: A single individual or a family composed of two or more
persons for which household incomes are used to determine eligibility and
for calculation of the resident rent payment. The term is used for
collecting data on changes in income, changes in access to services, receipt
of housing information services, and outcomes on achieving housing
stability. Live-In Aides (see definition for Live-In Aide) and non-
beneficiaries (e.g. a shared housing arrangement with a roommate) who
resided in the unit are not reported on in the CAPER.
Housing Stability: The degree to which the HOPWA project assisted
beneficiaries to remain in stable housing during the operating year. See
Part 5: Determining Housing Stability Outcomes for definitions of stable
and unstable housing situations.
In-kind Leveraged Resources: These 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 HOPWA Grantee Oversight Resource Guide for additional
reference.
Master Leasing: Applies to a nonprofit or public agency that leases units
of housing (scattered-sites or entire buildings) from a landlord, and
subleases the units to homeless or low-income tenants. By assuming the
tenancy burden, the agency facilitates housing of clients who may not be
able to maintain a lease on their own due to poor credit, evictions, or lack
of sufficient income.
Operating Costs: Applies to facility-based housing only, for facilities
that are currently open. Operating costs can include day-to-day housing
______________________________________________________________________________________
Previous editions are obsolete Page iii form HUD-40110-D (Expiration Date: 10/31/2017)
function and operation costs like utilities, maintenance, equipment,
insurance, security, furnishings, supplies and salary for staff costs directly
related to the housing project but not staff costs for delivering services.
Outcome: The degree to which the HOPWA assisted household has been
enabled to establish or maintain a stable living environment in housing that
is safe, decent, and sanitary, (per the regulations at 24 CFR 574.310(b))
and to reduce the risks of homelessness, and improve access to HIV
treatment and other health care and support.
Output: The number of units of housing or households that receive
HOPWA assistance during the operating year.
Permanent Housing Placement: A supportive housing service that helps
establish the household in the housing unit, including but not limited to
reasonable costs for security deposits not to exceed two months of rent
costs.
Program Income: Gross income directly generated from the use of
HOPWA funds, including repayments. See grant administration
requirements on program income for state and local governments at 24
CFR 85.25, or for non-profits at 24 CFR 84.24.
Project-Based Rental Assistance (PBRA): A rental subsidy program
that is tied to specific facilities or units owned or controlled by a project
sponsor or Subrecipient. Assistance is tied directly to the properties and is
not portable or transferable.
Project Sponsor Organizations: Any nonprofit organization or
governmental housing agency that receives 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.
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.
______________________________________________________________________________________
Previous editions are obsolete Page 1 form HUD-40110-D (Expiration Date: 10/31/2017)
Transgender: Transgender is defined as a person who identifies with, or presents as, a gender that is different from his/her gender at birth.
OMB Number 2506-0133 (Expiration Date: 10/31/2017)
Part 1: Grantee Executive Summary
As applicable, complete the charts below to provide more detailed information about the agencies and organizations responsibl e
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 carr ying
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
Operating Year for this report
From (mm/dd/yy) To (mm/dd/yy)
Grantee Name
Business Address
City, County, State, Zip
Employer Identification Number (EIN) or
Tax Identification Number (TIN)
DUN & Bradstreet Number (DUNs): Central Contractor Registration (CCR):
Is the grantee’s CCR status currently active?
Yes No
If yes, provide CCR Number:
Congressional District of Grantee’s Business
Address
*Congressional District of Primary Service
Area(s)
*City(ies) and County(ies) of Primary Service
Area(s)
Cities: Counties:
Organization’s Website Address
Is there a waiting list(s) for HOPWA Housing Subsidy Assistance
Services in the Grantee service Area? Yes No
If yes, explain in the narrative section what services maintain a waiting
list and how this list is administered.
* Service delivery area information only needed for program activities being directly carried out by the grantee .
Housing Opportunities for Person with AIDS (HOPWA)
Consolidated Annual Performance and Evaluation Report (CAPER)
Measuring Performance Outputs and Outcomes
______________________________________________________________________________________
Previous editions are obsolete Page 2 form HUD-40110-D (Expiration Date: 10/31/2017)
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 element s
address requirements in the Federal Financial Accountability and Transparency Act of 2006 (Public Law 109-282).
Note: Please see the definitions for distinctions between project sponsor and subrecipient.
Note: If any information does not apply to your organization, please enter N/A.
Project Sponsor Agency Name
Parent Company Name, if applicable
Name and Title of Contact at Project
Sponsor Agency
Email Address
Business Address
City, County, State, Zip,
Phone Number (with area code)
Employer Identification Number (EIN) or
Tax Identification Number (TIN)
Fax Number (with area code)
DUN & Bradstreet Number (DUNs):
Congressional District of Project Sponsor’s
Business Address
Congressional District(s) of Primary Service
Area(s)
City(ies) and County(ies) of Primary Service
Area(s)
Cities: Counties:
Total HOPWA contract amount for this
Organization for the operating year
Organization’s Website Address
Is the sponsor a nonprofit organization? Yes No
Please check if yes and a faith-based organization.
Please check if yes and a grassroots organization.
Does your organization maintain a waiting list? Yes No
If yes, explain in the narrative section how this list is administered.
______________________________________________________________________________________
Previous editions are obsolete Page 3 form HUD-40110-D (Expiration Date: 10/31/2017)
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 fo rms of financial assistance; and contracts,
subcontracts, purchase orders, task orders, and delivery orders. (Organizations listed may have contracts with project sponsors)
These elements address requirements in the Federal Funding and Accountability and Transparency Act of 2006 (Public Law 109 -
282).
Note: Please see the definitions for distinctions between project sponsor and subrecipient.
Note: If any information does not apply to your organization, please enter N/A.
Subrecipient Name
Parent Company Name, if applicable
Name and Title of Contact at Subrecipient
Email Address
Business Address
City, State, Zip, County
Phone Number (with area code) Fax Number (include 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)
Cities: Counties:
Total HOPWA Subcontract Amount of this
Organization for the operating year
______________________________________________________________________________________
Previous editions are obsolete Page 4 form HUD-40110-D (Expiration Date: 10/31/2017)
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 fo rms
of financial 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
Parent Company Name, if applicable
Name and Title of Contact at Contractor/
Sub-contractor Agency
Email Address
Business Address
City, County, State, Zip
Phone Number (included area code)
Fax Number (include 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
Cities:
Counties:
Total HOPWA Subcontract Amount of this
Organization for the operating year
______________________________________________________________________________________
Previous editions are obsolete Page 5 form HUD-40110-D (Expiration Date: 10/31/2017)
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 appr oved
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 ident ified
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. P rovide an explanation for each
barrier selected.
HOPWA/HUD Regulations
Discrimination/Confidentiality
Supportive Services
Housing Affordability
Planning
Multiple Diagnoses
Credit History
Housing Availability
Eligibility
Rental History
Rent Determination and Fair Market
Rents
Technical Assistance or Training
Criminal Justice History
Geography/Rural Access Other, please explain further
______________________________________________________________________________________
Previous editions are obsolete Page 6 form HUD-40110-D (Expiration Date: 10/31/2017)
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 7 form HUD-40110-D (Expiration Date: 10/31/2017)
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 8 form HUD-40110-D (Expiration Date: 10/31/2017)
PART 2: Sources of Leveraging and Program Income
1. Sources of Leveraging
Report the source(s) of cash or in-kind leveraged federal, state, local or private resources identified in the Consolidated or
Annual Plan and used in the delivery of the HOPWA program and the amount of leveraged dollars. In Column [1], identify the
type of leveraging. Some common sources of leveraged funds have been provided as a reference point. You may add Rows as
necessary to report all sources of leveraged funds. Include Resident Rent payments paid by clients directly to private landlords.
Do NOT include rents paid directly to a HOPWA program as this will be reported in the next section. In Column [2] report the
amount of leveraged funds expended during the operating year. Use Column [3] to provide some detail about the type of
leveraged contribution (e.g., case management services or clothing donations). In Column [4], check the appropriate box to
indicate whether the leveraged contribution was a housing subsidy assistance or another form of support.
Note: Be sure to report on the number of households supported with these leveraged funds in Part 3, Chart 1, Column d.
A. Source of Leveraging Chart
[1] Source of Leveraging
[2] Amount
of
Leveraged
Funds
[3] Type of
Contribution
[4] Housing Subsidy
Assistance or Other
Support
Public Funding
Ryan White-Housing Assistance
Housing Subsidy Assistance
Other Support
Ryan White-Other
Housing Subsidy Assistance
Other Support
Housing Choice Voucher Program
Housing Subsidy Assistance
Other Support
Low Income Housing Tax Credit
Housing Subsidy Assistance
Other Support
HOME
Housing Subsidy Assistance
Other Support
Shelter Plus Care
Housing Subsidy Assistance
Other Support
Emergency Solutions Grant
Housing Subsidy Assistance
Other Support
Other Public:
Housing Subsidy Assistance
Other Support
Other Public:
Housing Subsidy Assistance
Other Support
Other Public:
Housing Subsidy Assistance
Other Support
Other Public:
Housing Subsidy Assistance
Other Support
Other Public:
Housing Subsidy Assistance
Other Support
Private Funding
Grants
Housing Subsidy Assistance
Other Support
In-kind Resources
Housing Subsidy Assistance
Other Support
Other Private:
Housing Subsidy Assistance
Other Support
Other Private:
Housing Subsidy Assistance
Other Support
Other Funding
Grantee/Project Sponsor/Subrecipient (Agency) Cash
Housing Subsidy Assistance
Other Support
Resident Rent Payments by Client to Private Landlord
TOTAL (Sum of all Rows)
______________________________________________________________________________________
Previous editions are obsolete Page 9 form HUD-40110-D (Expiration Date: 10/31/2017)
2. Program Income and Resident Rent Payments
In Section 2, Chart A., report the total amount of program income and resident rent payments directly generated from the use of
HOPWA funds, including repayments. Include resident rent payments collected or paid directly to the HOPWA program. Do
NOT include payments made directly from a client household to a private landlord.
Note: Please see report directions section for definition of program income. (Additional information on program income is
available in the HOPWA Grantee Oversight Resource Guide).
A. Total Amount Program Income and Resident Rent Payment Collected During the Operating Year
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.
End of PART 2
Program Income and Resident Rent Payments Collected
Total Amount of
Program Income
(for this operating
year)
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)
Program Income and Resident Rent Payment Expended on
HOPWA programs
Total Amount of Program
Income Expended
(for this operating year)
1. Program Income and Resident Rent Payment Expended on Housing Subsidy Assistance costs
2. Program Income and Resident Rent Payment Expended on Supportive Services and other non-
direct housing costs
3. Total Program Income Expended (Sum of Rows 1 and 2)
______________________________________________________________________________________
Previous editions are obsolete Page 10 form HUD-40110-D (Expiration Date: 10/31/2017)
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 hous ing 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 funds and reported in PART 3 of the CAPER should be the same as reported
in the annual year-end IDIS data, and goals reported should be consistent with the Annual Plan information. Any discrepancies
or deviations should be explained in the narrative section of PART 1.
1. HOPWA Performance Planned Goal and Actual Outputs
HOPWA Performance
Planned Goal
and Actual
[1] Output: Households [2] Output: Funding
HOPWA
Assistance
Leveraged
Households HOPWA Funds
a. b. c. d. e. f.
Goal Actual Goal Actual HOPWA Budget HOPWA Actual
HOPWA Housing Subsidy Assistance [1] Output: Households [2] Output: Funding
1. Tenant-Based Rental Assistance
2a. Permanent Housing Facilities:
Received Operating Subsidies/Leased units (Households Served)
2b. Transitional/Short-term Facilities:
Received Operating Subsidies/Leased units (Households Served)
(Households Served)
3a. Permanent Housing Facilities:
Capital Development Projects placed in service during the operating year
(Households Served)
3b. Transitional/Short-term Facilities:
Capital Development Projects placed in service during the operating year
(Households Served)
4. Short-Term Rent, Mortgage and Utility Assistance
5. Permanent Housing Placement Services
6. Adjustments for duplication (subtract)
7. Total HOPWA Housing Subsidy Assistance
(Columns a. – d. equal the sum of Rows 1-5 minus Row 6; Columns e. and f.
equal the sum of Rows 1-5)
Housing Development (Construction and Stewardship of facility based housing)
[1] Output: Housing Units [2] Output: Funding
8. Facility-based units;
Capital Development Projects not yet opened (Housing Units)
9. Stewardship Units subject to 3 or 10 year use agreements
10. Total Housing Developed
(Sum of Rows 8 & 9)
Supportive Services [1] Output Households [2] Output: Funding
11a. Supportive Services provided by project sponsors/subrecipient that also delivered
HOPWA housing subsidy assistance
11b. Supportive Services provided by project sponsors/subrecipient that only provided
supportive services.
12. Adjustment for duplication (subtract)
13. Total Supportive Services
(Columns a. – d. equal the sum of Rows 11 a. & b. minus Row 12; Columns e. and
f. equal the sum of Rows 11a. & 11b.)
Housing Information Services
[1] Output Households
[2] Output: Funding
14. Housing Information Services
15. Total Housing Information Services
______________________________________________________________________________________
Previous editions are obsolete Page 11 form HUD-40110-D (Expiration Date: 10/31/2017)
Grant Administration and Other Activities
[1] Output Households
[2] Output: Funding
16. Resource Identification to establish, coordinate and develop housing assistance resources
17. Technical Assistance
(if approved in grant agreement)
18. Grantee Administration
(maximum 3% of total HOPWA grant)
19. Project Sponsor Administration
(maximum 7% of portion of HOPWA grant awarded)
20. Total Grant Administration and Other Activities
(Sum of Rows 16 – 19)
Total Expended [2] Outputs: HOPWA Funds
Expended
Budget Actual
21. Total Expenditures for program year (Sum of Rows 7, 10, 13, 15, and 20)
2. Listing of Supportive Services
Report on the households served and use of HOPWA funds for all supportive services. Do NOT report on supportive services
leveraged with non-HOPWA funds.
Data check: Total unduplicated households and expenditures reported in Row 17 equal totals reported in Part 3, Chart 1, Row 13.
Supportive Services [1] Output: Number of Households [2] Output: Amount of HOPWA Funds
Expended
1. Adult day care and personal assistance
2. Alcohol and drug abuse services
3. Case management
4. Child care and other child services
5. Education
6. Employment assistance and training
7.
Health/medical/intensive care services, if approved
Note: Client records must conform with 24 CFR §574.310
8. Legal services
9. Life skills management (outside of case management)
10. Meals/nutritional services
11. Mental health services
12. Outreach
13. Transportation
14.
Other Activity (if approved in grant agreement).
Specify:
15.
Sub-Total Households receiving Supportive Services
(Sum of Rows 1-14)
16. Adjustment for Duplication (subtract)
17.
TOTAL Unduplicated Households receiving
Supportive Services (Column [1] equals Row 15
minus Row 16; Column [2] equals sum of Rows 1-14)
______________________________________________________________________________________
Previous editions are obsolete Page 12 form HUD-40110-D (Expiration Date: 10/31/2017)
3. Short-Term Rent, Mortgage and Utility Assistance (STRMU) Summary
In Row a., enter the total number of households served and the amount of HOPWA funds expended on Short -Term Rent,
Mortgage and Utility (STRMU) Assistance. In Row b., enter the total number of STRMU-assisted households that received
assistance with mortgage costs only (no utility costs) and the amount expended assisting these households. In Row c., enter the
total number of STRMU -assisted households that received assistance with both mortgage and utility costs and the amount
expended assisting these households. In Row d., enter the total number of STRMU-assisted households that received assistance
with rental costs only (no utility costs) and the amount expended assisting these households. In Row e., enter the total number of
STRMU-assisted households that received assistance with both rental and utility costs and the amount expended assisting these
households. In Row f., enter the total number of STRMU -assisted households that received assistance with utility costs only (not
including rent or mortgage costs) and the amount expended assisting these households. In row g., report the amount of STRMU
funds expended to support direct program costs such as program operation staff.
Data Check: The total households reported as served with STRMU in Row a., column [1] and the total amount of HOPWA funds reported as
expended in Row a., column [2] equals the household and expenditure tota l reported for STRMU in Part 3, Chart 1, Row 4, Columns b. and f.,
respectively.
Data Check: The total number of households reported in Column [1], Rows b., c., d., e., and f. equal the total number of STRMU households
reported in Column [1], Row a. The total amount reported as expended in Column [2], Rows b., c., d., e., f., and g. equal the total amount of
STRMU expenditures reported in Column [2], Row a.
Housing Subsidy Assistance Categories (STRMU)
[1] Output: Number of
Households Served
[2] Output: Total
HOPWA Funds Expended
on STRMU during
Operating Year
a. Total Short-term mortgage, rent and/or utility (STRMU)
assistance
b. Of the total STRMU reported on Row a, total who received
assistance with mortgage costs ONLY.
c.
Of the total STRMU reported on Row a, total who received
assistance with mortgage and utility costs.
d.
Of the total STRMU reported on Row a, total who received
assistance with rental costs ONLY.
e. Of the total STRMU reported on Row a, total who received
assistance with rental and utility costs.
f. Of the total STRMU reported on Row a, total who received
assistance with utility costs ONLY.
g.
Direct program delivery costs (e.g., program operations staff
time)
End of PART 3
______________________________________________________________________________________
Previous editions are obsolete Page 13 form HUD-40110-D (Expiration Date: 10/31/2017)
Part 4: Summary of Performance Outcomes
In Column [1], report the total number of eligible households that received HOPWA housing subsidy assistance, by type.
In Column [2], enter the number of households that continued to access each type of housing subsidy assistance into next
operating year. In Column [3], report the housing status of all households that exited the program.
Data Check: The sum of Columns [2] (Number of Households Continuing) and [3] (Exited Households) equals the total reported in Column[1].
Note: Refer to the housing stability codes that appear in Part 5: Worksheet - Determining Housing Stability Outcomes.
Section 1. Housing Stability: Assessment of Client Outcomes on Maintaining Housing Stability (Permanent Housing and
Related Facilities)
A. Permanent Housing Subsidy Assistance
[1] Output: Total
Number of
Households
Served
[2] Assessment: Number of
Households that Continued
Receiving HOPWA Housing
Subsidy Assistance into the Next
Operating Year
[3] Assessment: Number of
Households that exited this
HOPWA Program; their Housing
Status after Exiting
[4] HOPWA Client
Outcomes
Tenant-Based
Rental
Assistance
1 Emergency Shelter/Streets Unstable Arrangements
2 Temporary Housing Temporarily Stable, with
Reduced Risk of Homelessness
3 Private Housing
Stable/Permanent Housing (PH)
4 Other HOPWA
5 Other Subsidy
6 Institution
7 Jail/Prison
Unstable Arrangements
8 Disconnected/Unknown
9 Death Life Event
Permanent
Supportive
Housing
Facilities/ Units
1 Emergency Shelter/Streets Unstable Arrangements
2 Temporary Housing Temporarily Stable, with
Reduced Risk of Homelessness
3 Private Housing
Stable/Permanent Housing (PH)
4 Other HOPWA
5 Other Subsidy
6 Institution
7 Jail/Prison
Unstable Arrangements 8 Disconnected/Unknown
9 Death Life Event
B. Transitional Housing Assistance
[1] Output: Total
Number of
Households
Served
[2] Assessment: Number of
Households that Continued
Receiving HOPWA Housing
Subsidy Assistance into the Next
Operating Year
[3] Assessment: Number of
Households that exited this
HOPWA Program; their
Housing Status after Exiting
[4] HOPWA Client Outcomes
Transitional/
Short-Term
Housing
Facilities/ Units
1 Emergency Shelter/Streets Unstable Arrangements
2 Temporary Housing Temporarily Stable with Reduced
Risk of Homelessness
3 Private Housing
Stable/Permanent Housing (PH)
4 Other HOPWA
5 Other Subsidy
6 Institution
7 Jail/Prison
Unstable Arrangements
8 Disconnected/unknown
9 Death Life Event
______________________________________________________________________________________
Previous editions are obsolete Page 14 form HUD-40110-D (Expiration Date: 10/31/2017)
B1:Total number of households receiving transitional/short-term housing
assistance whose tenure exceeded 24 months
Section 2. Prevention of Homelessness: Assessment of Client Outcomes on Reduced Risks of Homelessness
(Short-Term Housing Subsidy Assistance)
Report the total number of households that received STRMU assistance in Column [1].
In Column [2], identify the outcomes of the households reported in Column [1] either at the time that they were known to have
left the STRMU program or through the projec t 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 1a., report those households that received STRMU assistance during the operating year of this report, and the
prior operating year.
In Row 1b., report those households that received STRMU assistance during the operating year of this report, and the
two prior operating years.
Data Check: The total households reported as served with STRMU in Column [1] equals the total reported in Part 3, Chart 1,
Row 4, Column b.
Data Check: The sum of Column [2] should equal the number of households reported in Column [1].
Assessment of Households that Received STRMU Assistance
[1] Output: Total
number of
households
[2] Assessment of Housing Status [3] HOPWA Client Outcomes
Maintain Private Housing without subsidy
(e.g. Assistance provided/completed and client is stable, not
likely to seek additional support)
Stable/Permanent Housing (PH)
Other Private Housing without subsidy
(e.g. client switched housing units and is now stable, not likely
to seek additional support)
Other HOPWA Housing Subsidy Assistance
Other Housing Subsidy (PH)
Institution
(e.g. residential and long-term care)
Likely that additional STRMU is needed to maintain current
housing arrangements
Temporarily Stable, with
Reduced Risk of Homelessness
Transitional Facilities/Short-term
(e.g. temporary or transitional arrangement)
Temporary/Non-Permanent Housing arrangement
(e.g. gave up lease, and moved in with family or friends but
expects to live there less than 90 days)
Emergency Shelter/street
Unstable Arrangements Jail/Prison
Disconnected
Death Life Event
1a. Total number of those households that received STRMU Assistance in the operating year of this report that also received
STRMU assistance in the prior operating year (e.g. households that received STRMU assistance in two consecutive operating
years).
1b. Total number of those households that received STRMU Assistance in the operating year of this report that also received
STRMU assistance in the two prior operating years (e.g. households that received STRMU assistance in three consecutive
operating years).
______________________________________________________________________________________
Previous editions are obsolete Page 15 form HUD-40110-D (Expiration Date: 10/31/2017)
Section 3. HOPWA Outcomes on Access to Care and Support
1a. Total Number of Households
Line [1]: For project sponsors/subrecipients that provided HOPWA housing subsidy assistance during the operating year
identify in the appropriate row the numb er 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 percentage of households who demonstrated or maintained connections to care and
support as identified in Chart 1b. 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
1b. 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 1a., Row 1d. 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 1a., Row 2b., report the number of households that demonstrated
improved access or maintained connections to care and support within th e program year.
Note: For information on types and sources of income and medical insurance/assistance, refer to Charts below.
Categories of Services Accessed
[1] For project
sponsors/subrecipients that
provided HOPWA housing subsidy
assistance, identify the households
who demonstrated the following:
[2] For project
sponsors/subrecipients that
did NOT provide HOPWA
housing subsidy assistance,
identify the households who
demonstrated the following:
Outcome
Indicator
1. Has a housing plan for maintaining or establishing stable on-
going housing
Support for
Stable
Housing
2. Had contact with case manager/benefits counselor consistent
with the schedule specified in client’s individual service plan
(may include leveraged services such as Ryan White Medical
Case Management)
Access to
Support
3. Had contact with a primary health care provider consistent
with the schedule specified in client’s individual service plan
Access to
Health Care
4. Accessed and maintained medical insurance/assistance
Access to
Health Care
5. Successfully accessed or maintained qualification for sources
of income
Sources of
Income
______________________________________________________________________________________
Previous editions are obsolete Page 16 form HUD-40110-D (Expiration Date: 10/31/2017)
Chart 1b., Line 4: Sources of Medical Insurance and Assistance include, but are not limited to the following
(Reference only)
MEDICAID Health Insurance Program, or
use local program
name
MEDICARE Health Insurance Program, or
use local program name
Veterans Affairs Medical Services
AIDS Drug Assistance Program (ADAP)
State Children’s Health Insurance Program
(SCHIP), or use local program name
Ryan White-funded Medical or Dental
Assistance
Chart 1b., Row 5: Sources of Income include, but are not limited to the following (Reference only)
Earned Income
Veteran’s Pension
Unemployment Insurance
Pension from Former Job
Supplemental Security Income (SSI)
Child Support
Social Security Disability Income (SSDI)
Alimony or other Spousal Support
Veteran’s Disability Payment
Retirement Income from Social Security
Worker’s Compensation
General Assistance (GA), or use local
program name
Private Disability Insurance
Temporary Assistance for Needy
Families (TANF)
Other Income Sources
1c. Households that Obtained Employment
Column [1]: Of the households identified as receiving services from project sponsors/subrecipients that provided HOPWA
housing subsidy assistance as identified in Chart 1a., Row 1d. above, report on the number of households that include
persons who obtained an income-producing job during the operating year that resulted from HOPWA-funded Job training,
employment assistance, education or related case management/counseling services.
Column [2]: Of the households identified as receiving services from project sponsors /subrecipients that did NOT provide
HOPWA housing subsidy assistance as reported in Chart 1a., Row 2b., report on the number of households that include
persons who obtained an income-producing job during the operating year that resulted from HOPWA -funded Job training,
employment assistance, education or case management/counseling services.
Note: This includes jobs created by this project sponsor/subrecipients or obtained outside this agency.
Note: Do not include jobs that resulted from leveraged job training, employment a ssistance, education or case
management/counseling services.
Categories of Services Accessed
[1 For project sponsors/subrecipients that
provided HOPWA housing subsidy
assistance, identify the households who
demonstrated the following:
[2] For project sponsors/subrecipients that did
NOT provide HOPWA housing subsidy assistance,
identify the households who demonstrated the
following:
Total number of households that
obtained an income-producing job
End of PART 4
______________________________________________________________________________________
Previous editions are obsolete Page 17 form HUD-40110-D (Expiration Date: 10/31/2017)
PART 5: Worksheet - Determining Housing Stability Outcomes (optional)
1. This chart is designed to assess program results based on the information reported in Part 4 and to help Grantees determine
overall program performance. Completion of this worksheet is optional.
Permanent
Housing Subsidy
Assistance
Stable Housing
(# of households
remaining in program
plus 3+4+5+6)
Temporary Housing
(2)
Unstable
Arrangements
(1+7+8)
Life Event
(9)
Tenant-Based
Rental Assistance
(TBRA)
Permanent Facility-
based Housing
Assistance/Units
Transitional/Short-
Term Facility-based
Housing
Assistance/Units
Total Permanent
HOPWA Housing
Subsidy Assistance
Reduced Risk of
Homelessness:
Short-Term
Assistance
Stable/Permanent
Housing
Temporarily Stable, with Reduced Risk of
Homelessness
Unstable
Arrangements
Life Events
Short-Term Rent,
Mortgage, and
Utility Assistance
(STRMU)
Total HOPWA
Housing Subsidy
Assistance
Background on HOPWA Housing Stability Codes
Stable Permanent Housing/Ongoing Participation
3 = Private Housing in the private rental or home ownership market (without known subsidy, including permanent placement
with families or other self-sufficient arrangements) with reasonable expectation that additional support is not needed.
4 = Other HOPWA-funded housing subsidy assistance (not STRMU), e.g. TBRA or Facility-Based Assistance.
5 = Other subsidized house or apartment (non -HOPWA sources, e.g., Section 8, HOME, public housing).
6 = Institutional setting with greater support and continued residence expected (e.g., residential or long -term care facility).
Temporary Housing
2 = Temporary housing - moved in with family/friends or other short-term arrangement, such as Ryan White subsidy, transitional
housing for homeless, or temporary placement in institution (e.g., hospital, psychiatric hospital or other psychiatric facili ty,
substance abuse treatment facility or detox center).
Unstable Arrangements
1 = Emergency shelter or no housing destination such as places not meant for habitation (e.g., a vehicle, an abandoned building,
bus/train/subway station, or anywhere outside).
7 = Jail /prison.
8 = Disconnected or disappeared from project support, unknown destination or no assessments of housing needs were
undertaken.
Life Event
9 = Death, i.e., remained in housing until death. This characteristic is not factored into the housing stability equation.
Tenant-based Rental Assistance: Stable Housing is the sum of the number of households that (i) remain in the housing and (ii)
those that left the assistance as reported under: 3, 4, 5, and 6. Temporary Housing is the number of households that accessed
assistance, and left their current housing for a non -permanent housing arrangement, as reported under item: 2. Unstable
Situations is the sum of numbers reported under items: 1, 7, and 8.
______________________________________________________________________________________
Previous editions are obsolete Page 18 form HUD-40110-D (Expiration Date: 10/31/2017)
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, a nd 6. Other Temporary Housing is the
number of households that accessed assistance, and left their current housing for a non -permanent housing arrangement, as
reported under item 2. Unstable Situations is the sum of numbers reported under items: 1, 7, and 8.
Tenure Assessment. A baseline of households in transitional/short-term facilities for assessment purposes, indicate the number
of households whose tenure exceeded 24 months.
STRMU Assistance: Stable Housing is the sum of the number of households that accessed assistance for some portion of the
permitted 21-week period and there is reasonable expectation that additional support is not needed in order to maintain
permanent housing living situation (as this is a time -limited form of housing support) as reported under housing status: Maintain
Private Housing with subsidy; Other Private with Subsidy; Other HOPWA support; Other Housing Subsidy; and Institution .
Temporarily Stable, with Reduced Risk of Homelessness is the sum of the number of households that accessed assistance for
some portion of the permitted 21-week period or left their current housing arrangement for a transitional facility or other
temporary/non-permanent housing arrangement and there is reasonable expectation additional support will be needed to maintain
housing arrangements in the next year, as reported under housing status: Likely to maintain current housing arrangements, with
additional STRMU assistance; Transitional Facilities/Short-term; and Temporary/Non-Permanent Housing arrangements
Unstable Situation is the sum of number of households reported under housing status: Emergency Shelter; Jail/Prison; and
Disconnected.
End of PART 5
______________________________________________________________________________________
Previous editions are obsolete Page 19 form HUD-40110-D (Expiration Date: 10/31/2017)
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 are required to operate for at least three (3) years. Stewardship begins once the facility is put into
operation.
Note: See definition of Stewardship Units.
1. General information
HUD Grant Number(s)
Operating Year for this report
From (mm/dd/yy) To (mm/dd/yy) Final Yr
Yr 1; Yr 2; Yr 3; Yr 4; Yr 5; Yr 6;
Yr 7; Yr 8; Yr 9; Yr 10;
Grantee Name
Date Facility Began Operations (mm/dd/yy)
2. Number of Units and Non-HOPWA Expenditures
Facility Name: Number of Stewardship Units
Developed with HOPWA
funds
Amount of Non-HOPWA Funds Expended in Support of the
Stewardship Units during the Operating Year
Total Stewardship Units
(subject to 3- or 10- year use periods)
3. Details of Project Site
Project Sites: Name of HOPWA-funded project
Site Information: Project Zip Code(s)
Site Information: Congressional District(s)
Is the address of the project site confidential? Yes, protect information; do not list
Not confidential; information can be made available to the public
If the site is not confidential:
Please provide the contact information, phone,
email address/location, if business address is
different from facility address
I certify that the facility that received assistance for acquisition, rehabilitation, or new construction from the Housing Op portunities
for Persons with AIDS Program has operated as a facility to assist HOPWA-eligible persons from the date shown above. I also
certify that the grant is still serving the planned number of HOPWA-eligible households at this facility through leveraged resources
and all other requirements of the grant agreement are being satisfied.
I hereby certify that all the information stated herein, as well as any information provided in the accompaniment herewith, i s true and accurate.
Name & Title of Authorized Official of the organization that continues
to operate the facility:
Signature & Date (mm/dd/yy)
Name & Title of Contact at Grantee Agency
(person who can answer questions about the report and program)
Contact Phone (with area code)
End of PART 6
______________________________________________________________________________________
Previous editions are obsolete Page 20 form HUD-40110-D (Expiration Date: 10/31/2017)
Part 7: Summary Overview of Grant Activities
A. Information on Individuals, Beneficiaries, and Households Receiving HOPWA Housing Subsidy Assistance
(TBRA, STRMU, Facility-Based Units, Permanent Housing Placement and Master Leased Units ONLY)
Note: Reporting for this section should include ONLY those individuals, beneficiaries, or households that received and/or
resided in a household that received HOPWA Housing Subsidy Assistance as reported in Part 3, Chart 1, Row 7, Column b.
(e.g., do not include households that received HOPWA supportive services ONLY).
Section 1. HOPWA-Eligible Individuals who Received HOPWA Housing Subsidy Assistance
a. Total HOPWA Eligible Individuals Living with HIV/AIDS
In Chart a., provide the total number of eligible (and unduplicated) low-income individuals living with HIV/AIDS who qualified
their household to receive HOPWA housing subsidy assistance during the operating year. This total should include only the
individual who qualified the household for HOPWA assistance , NOT all HIV positive individuals in the household.
Individuals Served with Housing Subsidy Assistance Total
Number of individuals with HIV/AIDS who qualified their household to receive HOPWA housing subsidy assistance.
Chart b. Prior Living Situation
In Chart b., report the prior living situations for all Eligible Individuals reported in Chart a. In Row 1, report the total number of
individuals who continued to receive HOPWA housing subsidy assistance from the prior operating year into this operating year.
In Rows 2 through 17, indicate the prior living arrangements for all new HOPWA housing subsidy assistance recipients during
the operating year.
Data Check: The total number of eligible individuals served in Row 18 equal s the total number of individuals served through
housing subsidy assistance reported in Chart a. above.
Category
Total HOPWA
Eligible Individuals
Receiving Housing
Subsidy Assistance
1. Continuing to receive HOPWA support from the prior operating year
New Individuals who received HOPWA Housing Subsidy Assistance support during Operating Year
2. Place not meant for human habitation
(such as a vehicle, abandoned building, bus/train/subway station/airport, or outside)
3. Emergency shelter (including hotel, motel, or campground paid for with emergency shelter voucher)
4. Transitional housing for homeless persons
5. Total number of new Eligible Individuals who received HOPWA Housing Subsidy Assistance with a Prior
Living Situation that meets HUD definition of homelessness (Sum of Rows 2 – 4)
6. Permanent housing for formerly homeless persons (such as Shelter Plus Care, SHP, or SRO Mod
Rehab)
7. Psychiatric hospital or other psychiatric facility
8. Substance abuse treatment facility or detox center
9. Hospital (non-psychiatric facility)
10. Foster care home or foster care group home
11. Jail, prison or juvenile detention facility
12. Rented room, apartment, or house
13. House you own
14. Staying or living in someone else’s (family and friends) room, apartment, or house
15. Hotel or motel paid for without emergency shelter voucher
16. Other
17. Don’t Know or Refused
18. TOTAL Number of HOPWA Eligible Individuals (sum of Rows 1 and 5-17)
______________________________________________________________________________________
Previous editions are obsolete Page 21 form HUD-40110-D (Expiration Date: 10/31/2017)
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 C APER). The totals in Chart c. do not need to
equal the total in Chart b., Row 5.
Category
Number of
Homeless
Veteran(s)
Number of Chronically
Homeless
HOPWA eligible individuals served with
HOPWA Housing Subsidy Assistance
Section 2. Beneficiaries
In Chart a., report the total number of HOPWA eligible individuals living with HIV/AIDS who received HOPWA housing
subsidy assistance (as reported in Part 7A, Section 1, Chart a.), and all associated members of their household who benefitted
from receiving HOPWA housing subsidy assistance (resided with HOPWA eligible individuals ).
Note: See definition of HOPWA Eligible Individual
Note: See definition of Transgender.
Note: See definition of Beneficiaries.
Data Check: The sum of each of the Charts b. & c. on the following two pages equals the total number of beneficiaries served
with HOPWA housing subsidy assistance as determined in Chart a., Row 4 below.
a. Total Number of Beneficiaries Served with HOPWA Housing Subsidy Assistance
Individuals and Families Served with HOPWA Housing Subsidy Assistance Total Number
1. Number of individuals with HIV/AIDS who qualified the household to receive HOPWA hou sing 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)
______________________________________________________________________________________
Previous editions are obsolete Page 22 form HUD-40110-D (Expiration Date: 10/31/2017)
b. Age and Gender
In Chart b., indicate the Age and Gender of all beneficiaries as reported in Chart a. directly above. Report the Age and Gender of
all HOPWA Eligible Individuals (those reported in Chart a., Row 1) using Rows 1-5 below and the Age and Gender of all other
beneficiaries (those reported in Chart a., Rows 2 and 3) using Rows 6-10 below. The number of individuals reported in Row 11,
Column E. equals the total number of beneficiaries reported in Part 7, Section 2, Chart a., Row 4.
HOPWA Eligible Individuals (Chart a, Row 1)
A. B. C. D. E.
Male Female Transgender M to F Transgender F to M
TOTAL (Sum of
Columns A-D)
1. Under 18
2. 18 to 30 years
3. 31 to 50 years
4.
51 years and
Older
5.
Subtotal (Sum
of Rows 1-4)
All Other Beneficiaries (Chart a, Rows 2 and 3)
A. B. C. D. E.
Male Female Transgender M to F Transgender F to M
TOTAL (Sum of
Columns A-D)
6. Under 18
7. 18 to 30 years
8. 31 to 50 years
9.
51 years and
Older
10.
Subtotal (Sum
of Rows 6-9)
Total Beneficiaries (Chart a, Row 4)
11.
TOTAL (Sum
of Rows 5 & 10)
______________________________________________________________________________________
Previous editions are obsolete Page 23 form HUD-40110-D (Expiration Date: 10/31/2017)
c. Race and Ethnicity*
In Chart c., indicate the Race and Ethnicity of all beneficiaries receiving HOPWA Housing Subsidy Assistance as reported in
Section 2, Chart a., Row 4. Report the race of all HOPWA eligible individuals in Column [A]. Report the ethnicity of all
HOPWA eligible individuals in column [B]. Report the race of all other individuals who benefitted from the HOPWA housing
subsidy assistance in column [C]. Report the ethnicity of all other individuals who benefitted from the HOPWA housing subsidy
assistance in column [D]. The summed total of columns [A] and [C] equals the total number of beneficiaries reported above in
Section 2, Chart a., Row 4.
Category
HOPWA Eligible Individuals All Other Beneficiaries
[A] Race
[all individuals
reported in
Section 2, Chart
a., Row 1]
[B] Ethnicity
[Also identified as
Hispanic or
Latino]
[C] Race
[total of
individuals
reported in
Section 2, Chart
a., Rows 2 & 3]
[D] Ethnicity
[Also identified as
Hispanic or
Latino]
1. American Indian/Alaskan Native
2. Asian
3. Black/African American
4. Native Hawaiian/Other Pacific Islander
5. White
6. American Indian/Alaskan Native & White
7. Asian & White
8. Black/African American & White
9. American Indian/Alaskan Native &
Black/African American
10. Other Multi-Racial
11. Column Totals (Sum of Rows 1-10)
Data Check: Sum of Row 11 Column A and Row 11 Column C equals the total number HOPWA Beneficiaries reported in Part 3A, Section 2,
Chart a., Row 4.
*Reference (data requested consistent with Form HUD-27061 Race and Ethnic Data Reporting Form)
Section 3. Households
Household Area Median Income
Report the 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 http://www.huduser.org/portal/datasets/il/il2010/select_Geography_mfi.odn for information on area median
income in your community.
Percentage of Area Median Income Households Served with HOPWA Housing Subsidy
Assistance
1. 0-30% of area median income (extremely low)
2. 31-50% of area median income (very low)
3. 51-80% of area median income (low)
4. Total (Sum of Rows 1-3)
______________________________________________________________________________________
Previous editions are obsolete Page 24 form HUD-40110-D (Expiration Date: 10/31/2017)
Part 7: Summary Overview of Grant Activities
B. Facility-Based Housing Assistance
Complete one Part 7B for each facility developed or supported through HOPWA funds.
Do not complete this Section for programs originally developed with HOPWA funds but no longer supported with
HOPWA funds. If a facility was developed with HOPWA funds (subject to ten years of operation for acquisition, new
construction and substantial rehabilitation costs of stewardship units, or three years for non -substantial rehabilitation costs), but
HOPWA funds are no longer used to support the facility, the project sponsor or subrecipient should complete Part 6: Annual
Certification of Continued Usage for HOPWA Facility-Based Stewardship Units (ONLY).
Complete Charts 2a., Project Site Information, and 2b., Type of HOPWA Capital Development Project Units, for all
Development Projects, including facilities that were past development projects, but continued to receive HOPWA operating
dollars this reporting year.
1. Project Sponsor/Subrecipient Agency Name (Required)
2. Capital Development
2a. Project Site Information for HOPWA Capital Development of Projects (For Current or Past Capital
Development Projects that receive HOPWA Operating Costs this reporting year)
Note: If units are scattered-sites, report on them as a group and under type of Facility write “Scattered Sites.”
Type of
Development
this operating
year
HOPWA
Funds
Expended
this operating
year
(if applicable)
Non-HOPWA funds
Expended
(if applicable)
Name of Facility:
New construction $
$
Type of Facility [Check only one box.]
Permanent housing
Short-term Shelter or Transitional housing
Supportive services only facility
Rehabilitation $
$
Acquisition $
$
Operating $
$
a. Purchase/lease of property: Date (mm/dd/yy):
b. Rehabilitation/Construction Dates: Date started: Date Completed:
c. Operation dates: Date residents began to occupy:
Not yet occupied
d. Date supportive services began: Date started:
Not yet providing services
e. Number of units in the facility: HOPWA-funded units = Total Units =
f. Is a waiting list maintained for the facility? Yes No
If yes, number of participants on the list at the end of operating year
g. What is the address of the facility (if different from business address)?
h. Is the address of the project site confidential?
Yes, protect information; do not publish list
No, can be made available to the public
______________________________________________________________________________________
Previous editions are obsolete Page 25 form HUD-40110-D (Expiration Date: 10/31/2017)
2b. Number and Type of HOPWA Capital Development Project Units (For Current or Past Capital
Development Projects that receive HOPWA Operating Costs this Reporting Year)
For units entered above in 2a. please list the number of HOPWA units that fulfill the following criteria :
Number Designated
for the Chronically
Homeless
Number
Designated to
Assist the
Homeless
Number Energy-
Star Compliant Number 504 Accessible
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
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
Total Number of Units in use during the Operating Year
Categorized by the Number of Bedrooms per Units
SRO/Studio/0
bdrm 1 bdrm 2 bdrm 3 bdrm 4 bdrm 5+bdrm
a. Single room occupancy dwelling
b. Community residence
c. Project-based rental assistance units or leased units
d. Other housing facility
Specify:
4. Households and Housing Expenditures
Enter the total number of households served and the amount of HOPWA funds expended by the project sponsor/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 Output: Number of
Households
Output: Total HOPWA Funds Expended during
Operating Year by Project Sponsor/subrecipient
a. Leasing Costs
b. Operating Costs
c. Project-Based Rental Assistance (PBRA) or other leased units
d. Other Activity (if approved in grant agreement) Specify:
e. Adjustment to eliminate duplication (subtract)
f.
TOTAL Facility-Based Housing Assistance
(Sum Rows a. through d. minus Row e.)
HOPWA PSA CONTRACT 2021-2022 -- EXHIBIT “I” -- MBE REPORTING FORM Page 1
Tarrant County Samaritan Housing, Inc.
EXHIBIT “I”
MBE REPORTING FORM
HOPWA PSA CONTRACT 2021-2022 -- EXHIBIT “J” – DUTIES OF THE PARTIES—USE OF
NEIGHBORHOOD SERVICES DEPARTMENT COMMUNITY CENTERS Page 1
Tarrant County Samaritan Housing, Inc.
EXHIBIT “J”
DUTIES OF THE PARTIES
USE OF NEIGHBORHOOD SERVICES DEPARTMENT
COMMUNITY CENTERS
HOPWA PSA CONTRACT 2021-2022 -- EXHIBIT “J” – DUTIES OF THE PARTIES—USE OF
NEIGHBORHOOD SERVICES DEPARTMENT COMMUNITY CENTERS Page 1
Tarrant County Samaritan Housing
Tarrant County Samaritan Housing
DUTIES OF THE PARTIES
USE OF NEIGHBORHOOD SERVICES DEPARTMENT
COMMUNITY CENTERS
Agency’s Responsibilities:
Agency will perform the following in relation with the use of Community Center:
• Agency will furnish the Center Coordinator with a schedule of Program activities at least
four weeks prior to their occurrence.
• Agency will, at its sole expense, furnish materials, supplies, copies and conduct a structured
Program.
• Agency will ensure that the designated Community Center space is maintained in a neat
and orderly fashion.
• Agency will ensure that the City’s standards are maintained regarding security; cleanliness
and communication between and among programs housed at the Community Center and
will ensure cooperation with other Community Center staff and agencies/programs.
• Agency will report to the Center Coordinator or designee for problems immediately
if/when problems occur.
• Agency will work with the Center Coordinator or designee to schedule any use of the
Community Center for related activities outside of agencies designated meeting time and/or
the Community Center’s regular days and hours.
• Agency will maintain sole responsibility and liability for its employees, volunteers and
separate contractors for their actions.
• Agency shall ensure that each of its employees, volunteers and participants desiring to
participate in Community Center-sponsored programs/activities are aware of the
requirement to have a current community center membership card to participate.
• Agency agrees to perform background screenings and checks on staff and volunteers, with
such screenings and checks meeting or exceeding the requirements that the City imposes
for checks and screenings on staff, volunteers and participants in the City’s own programs.
• Agency will provide the Center Coordinator with designated staff contact information for
the purposes of emergencies (center closing, schedule changes or scheduled maintenance)
City’s Responsibilities:
HOPWA PSA CONTRACT 2021-2022 -- EXHIBIT “J” – DUTIES OF THE PARTIES—USE OF
NEIGHBORHOOD SERVICES DEPARTMENT COMMUNITY CENTERS Page 2
Tarrant County Samaritan Housing
City will perform the following in relation with Agency’s use of a Community Center:
• City will provide space for conducting the Program, including basic utilities and will also
supply the Agency with appropriate facility access. For purposes of this Contract, basic
utilities shall not include telephone or computer service, which shall remain the sole
responsibility of the Agency.
• City will ensure that the reserved space is set up with appropriate tables and chairs to
accommodate program and/or services.
• City will not be responsible for any additional security other than what is currently
available at the Community Center.
• City assumes no liability or responsibility for the loss of any personal property or office
contents of the Agency, its agents, employees, volunteers, participants or licensees while
at the Community Center.
• City will allow the Agency to conduct properly scheduled classes and other Program
related activities during the days and hours specified in Exhibit “A” PROGRAM
SUMMARY*. In addition, City may, but is not required, through the Center Coordinator,
allow Agency to schedule other classes and Program related activities outside of the days
and hours specified in Exhibit “A” PROGRAM SUMMARY.
• City will maintain sole responsibility and liability for its employees, volunteers and
separate contractors for their actions.
•
• City will have the discretion to put the Agency in any available room. If placed in a
different location, it is to be only one room.
*The City is closed in observance of the following holidays:
New Year’s Day (January 1st)
M.L.K. Jr. Day (Third Monday of January)
Memorial Day (Last Monday in May)
Independence Day (July 4th)
Labor Day (First Monday in September)
Thanksgiving Day (Fourth Thursday of November)
Day after Thanksgiving (Fourth Friday in November)
Christmas Day (December 25th)
**City of Fort Worth observes the above holidays on Friday if they fall on Saturday and on a Monday if they
fall on Sunday.
Additionally, the Community Centers are utilized as shelters during an emergency. If the
Community Center will be closed due to an emergency, Center Coordinator or designee will
inform Agency of the closure.
HOPWA PSA CONTRACT 2021-2022 -- EXHIBIT “K” – NOTICE OF BENEFICIARY RIGHTS Page 1
Tarrant County Samaritan Housing, Inc.
EXHIBIT “K”
NOTICE OF BENEFICIARY RIGHTS
HOPWA PSA CONTRACT 2021-2022 -- EXHIBIT “K” – NOTICE OF BENEFICIARY RIGHTS Page 2
Tarrant County Samaritan Housing, Inc.
Notice of Beneficiary Rights
Name of Agency: TARRANT COUNTY SAMARITAN HOUSE, INC.
Name of Program: HOPWA
Contact information for Program Staff (name, phone number, and e-mail address, if appropriate):
Because this program is supported in whole or in part by direct Federal financial assistance from
the Federal Government, we are required to let you know that:
• We may not discriminate against you on the basis of religion, religious belief, a refusal
to hold a religious belief, or a refusal to attend or participate in a religious practice;
• We may not require you to attend or participate in any explicitly religious activities that
are offered by us and any participation by you in these activities must be purely
voluntary;
• We must separate, in time or location, any privately funded explicitly religious activities
from activities supported by direct Federal financial assistance;
• If you object to the religious character of our organization, we must make reasonable
efforts to identify and refer you to an alternative provider to which you have no such
objection; and
• You may report an organization's violations of these protections, including any denial of
services or benefits, by contacting or filing a written complaint to HUD [or the
intermediary, if applicable].
We must give you this written notice before you enroll in our program or activity, as required by
24 CFR 5.109.
NOTICE OF OCCUPANCY RIGHTS UNDER
THE VIOLENCE AGAINST WOMEN ACT U.S. Department of Housing and Urban Development
OMB Approval No. 2577-0286
Expires 06/30/2017
Form HUD-5380
(12/2016)
EXHIBIT “L” – Notice of Occupancy Rights Under VAWA
[Insert Name of Housing Provider 1]
Notice of Occupancy Rights under the Violence Against Women Act 2
To all Tenants and Applicants
The Violence Against Women Act (VAWA) provides protections for victims of domestic
violence, dating violence, sexual assault, or stalking. VAWA protections are not only available
to women, but are available equally to all individuals regardless of sex, gender identity, or sexual
orientation.3 The U.S. Department of Housing and Urban Development (HUD) is the Federal
agency that oversees that [insert name of program or rental assistance] is in compliance with
VAWA. This notice explains your rights under VAWA. A HUD-approved certification form is
attached to this notice. You can fill out this form to show that you are or have been a victim of
domestic violence, dating violence, sexual assault, or stalking, and that you wish to use your
rights under VAWA.”
Protections for Applicants
If you otherwise qualify for assistance under [insert name of program or rental assistance],
you cannot be denied admission or denied assistance because you are or have been a victim of
domestic violence, dating violence, sexual assault, or stalking.
Protections for Tenants
1 The notice uses HP for housing provider but the housing provider should insert its name where HP is used.
HUD’s program-specific regulations identify the individual or entity responsible for providing the notice of
occupancy rights.
2 Despite the name of this law, VAWA protection is available regardless of sex, gender identity, or sexual
orientation.
3 Housing providers cannot discriminate on the basis of any protected characteristic, including race, color, national
origin, religion, sex, familial status, disability, or age. HUD-assisted and HUD-insured housing must be made
available to all otherwise eligible individuals regardless of actual or perceived sexual orientation, gender identity, or
marital status.
2
Form HUD-5380
(12/2016)
If you are receiving assistance under [insert name of program or rental assistance], you may
not be denied assistance, terminated from participation, or be evicted from your rental housing
because you are or have been a victim of domestic violence, dating violence, sexual assault, or
stalking.
Also, if you or an affiliated individual of yours is or has been the victim of domestic violence,
dating violence, sexual assault, or stalking by a member of your household or any guest, you
may not be denied rental assistance or occupancy rights under [insert name of program or
rental assistance] solely on the basis of criminal activity directly relating to that domestic
violence, dating violence, sexual assault, or stalking.
Affiliated individual means your spouse, parent, brother, sister, or child, or a person to whom
you stand in the place of a parent or guardian (for example, the affiliated individual is in your
care, custody, or control); or any individual, tenant, or lawful occupant living in your household.
Removing the Abuser or Perpetrator from the Household
HP may divide (bifurcate) your lease in order to evict the individual or terminate the assistance
of the individual who has engaged in criminal activity (the abuser or perpetrator) directly relating
to domestic violence, dating violence, sexual assault, or stalking.
If HP chooses to remove the abuser or perpetrator, HP may not take away the rights of eligible
tenants to the unit or otherwise punish the remaining tenants. If the evicted abuser or perpetrator
was the sole tenant to have established eligibility for assistance under the program, HP must
allow the tenant who is or has been a victim and other household members to remain in the unit
for a period of time, in order to establish eligibility under the program or under another HUD
housing program covered by VAWA, or, find alternative housing.
3
Form HUD-5380
(12/2016)
In removing the abuser or perpetrator from the household, HP must follow Federal, State, and
local eviction procedures. In order to divide a lease, HP may, but is not required to, ask you for
documentation or certification of the incidences of domestic violence, dating violence, sexual
assault, or stalking.
Moving to Another Unit
Upon your request, HP may permit you to move to another unit, subject to the availability of
other units, and still keep your assistance. In order to approve a request, HP may ask you to
provide documentation that you are requesting to move because of an incidence of domestic
violence, dating violence, sexual assault, or stalking. If the request is a request for emergency
transfer, the housing provider may ask you to submit a written request or fill out a form where
you certify that you meet the criteria for an emergency transfer under VAWA. The criteria are:
(1) You are a victim of domestic violence, dating violence, sexual assault, or
stalking. If your housing provider does not already have documentation that you
are a victim of domestic violence, dating violence, sexual assault, or stalking, your
housing provider may ask you for such documentation, as described in the
documentation section below.
(2) You expressly request the emergency transfer. Your housing provider may
choose to require that you submit a form, or may accept another written or oral
request.
(3) You reasonably believe you are threatened with imminent harm from
further violence if you remain in your current unit. This means you have a
reason to fear that if you do not receive a transfer you would suffer violence in the
very near future.
4
Form HUD-5380
(12/2016)
OR
You are a victim of sexual assault and the assault occurred on the premises
during the 90-calendar-day period before you request a transfer. If you are a
victim of sexual assault, then in addition to qualifying for an emergency transfer
because you reasonably believe you are threatened with imminent harm from
further violence if you remain in your unit, you may qualify for an emergency
transfer if the sexual assault occurred on the premises of the property from which
you are seeking your transfer, and that assault happened within the 90-calendar-day
period before you expressly request the transfer.
HP will keep confidential requests for emergency transfers by victims of domestic violence,
dating violence, sexual assault, or stalking, and the location of any move by such victims and
their families.
HP’s emergency transfer plan provides further information on emergency transfers, and HP must
make a copy of its emergency transfer plan available to you if you ask to see it.
Documenting You Are or Have Been a Victim of Domestic Violence, Dating Violence,
Sexual Assault or Stalking
HP can, but is not required to, ask you to provide documentation to “certify” that you are or have
been a victim of domestic violence, dating violence, sexual assault, or stalking. Such request
from HP must be in writing, and HP must give you at least 14 business days (Saturdays,
Sundays, and Federal holidays do not count) from the day you receive the request to provide the
documentation. HP may, but does not have to, extend the deadline for the submission of
documentation upon your request.
5
Form HUD-5380
(12/2016)
You can provide one of the following to HP as documentation. It is your choice which of the
following to submit if HP asks you to provide documentation that you are or have been a victim
of domestic violence, dating violence, sexual assault, or stalking.
• A complete HUD-approved certification form given to you by HP with this notice, that
documents an incident of domestic violence, dating violence, sexual assault, or stalking.
The form will ask for your name, the date, time, and location of the incident of domestic
violence, dating violence, sexual assault, or stalking, and a description of the incident.
The certification form provides for including the name of the abuser or perpetrator if the
name of the abuser or perpetrator is known and is safe to provide.
• A record of a Federal, State, tribal, territorial, or local law enforcement agency, court, or
administrative agency that documents the incident of domestic violence, dating violence,
sexual assault, or stalking. Examples of such records include police reports, protective
orders, and restraining orders, among others.
• A statement, which you must sign, along with the signature of an employee, agent, or
volunteer of a victim service provider, an attorney, a medical professional or a mental
health professional (collectively, “professional”) from whom you sought assistance in
addressing domestic violence, dating violence, sexual assault, or stalking, or the effects of
abuse, and with the professional selected by you attesting under penalty of perjury that he
or she believes that the incident or incidents of domestic violence, dating violence, sexual
assault, or stalking are grounds for protection.
• Any other statement or evidence that HP has agreed to accept.
If you fail or refuse to provide one of these documents within the 14 business days, HP does not
have to provide you with the protections contained in this notice.
6
Form HUD-5380
(12/2016)
If HP receives conflicting evidence that an incident of domestic violence, dating violence, sexual
assault, or stalking has been committed (such as certification forms from two or more members
of a household each claiming to be a victim and naming one or more of the other petitioning
household members as the abuser or perpetrator), HP has the right to request that you provide
third-party documentation within thirty 30 calendar days in order to resolve the conflict. If you
fail or refuse to provide third-party documentation where there is conflicting evidence, HP does
not have to provide you with the protections contained in this notice.
Confidentiality
HP must keep confidential any information you provide related to the exercise of your rights
under VAWA, including the fact that you are exercising your rights under VAWA.
HP must not allow any individual administering assistance or other services on behalf of HP (for
example, employees and contractors) to have access to confidential information unless for
reasons that specifically call for these individuals to have access to this information under
applicable Federal, State, or local law.
HP must not enter your information into any shared database or disclose your information to any
other entity or individual. HP, however, may disclose the information provided if:
• You give written permission to HP to release the information on a time limited basis.
• HP needs to use the information in an eviction or termination proceeding, such as to evict
your abuser or perpetrator or terminate your abuser or perpetrator from assistance under
this program.
• A law requires HP or your landlord to release the information.
7
Form HUD-5380
(12/2016)
VAWA does not limit HP’s duty to honor court orders about access to or control of the property.
This includes orders issued to protect a victim and orders dividing property among household
members in cases where a family breaks up.
Reasons a Tenant Eligible for Occupancy Rights under VAWA May Be Evicted or
Assistance May Be Terminated
You can be evicted and your assistance can be terminated for serious or repeated lease violations
that are not related to domestic violence, dating violence, sexual assault, or stalking committed
against you. However, HP cannot hold tenants who have been victims of domestic violence,
dating violence, sexual assault, or stalking to a more demanding set of rules than it applies to
tenants who have not been victims of domestic violence, dating violence, sexual assault, or
stalking.
The protections described in this notice might not apply, and you could be evicted and your
assistance terminated, if HP can demonstrate that not evicting you or terminating your assistance
would present a real physical danger that:
1) Would occur within an immediate time frame, and
2) Could result in death or serious bodily harm to other tenants or those who work on the
property.
If HP can demonstrate the above, HP should only terminate your assistance or evict you if there
are no other actions that could be taken to reduce or eliminate the threat.
Other Laws
VAWA does not replace any Federal, State, or local law that provides greater protection for
victims of domestic violence, dating violence, sexual assault, or stalking. You may be entitled to
8
Form HUD-5380
(12/2016)
additional housing protections for victims of domestic violence, dating violence, sexual assault,
or stalking under other Federal laws, as well as under State and local laws.
Non-Compliance with The Requirements of This Notice
You may report a covered housing provider’s violations of these rights and seek additional
assistance, if needed, by contacting or filing a complaint with [insert contact information for
any intermediary, if applicable] or [insert HUD field office].
For Additional Information
You may view a copy of HUD’s final VAWA rule at [insert Federal Register link].
Additionally, HP must make a copy of HUD’s VAWA regulations available to you if you ask to
see them.
For questions regarding VAWA, please contact [insert name of program or rental assistance
contact information able to answer questions on VAWA].
For help regarding an abusive relationship, you may call the National Domestic Violence Hotline
at 1-800-799-7233 or, for persons with hearing impairments, 1-800-787-3224 (TTY). You may
also contact [Insert contact information for relevant local organizations].
For tenants who are or have been victims of stalking seeking help may visit the National Center
for Victims of Crime’s Stalking Resource Center at https://www.victimsofcrime.org/our-
programs/stalking-resource-center.
For help regarding sexual assault, you may contact [Insert contact information for relevant
organizations]
Victims of stalking seeking help may contact [Insert contact information for relevant
organizations].
Attachment: Certification form HUD-5382 [form approved for this program to be included]
Form HUD-5382
(06/2017)
EXHIBIT “M” – Emergency Transfer Request Form
CERTIFICATION OF U.S. Department of Housing OMB Approval No. 2577-0286
DOMESTIC VIOLENCE, and Urban Development Exp. 06/30/2017
DATING VIOLENCE,
SEXUAL ASSAULT, OR STALKING,
AND ALTERNATE DOCUMENTATION
Purpose of Form: The Violence Against Women Act (“VAWA”) protects applicants, tenants, and
program participants in certain HUD programs from being evicted, denied housing assistance, or
terminated from housing assistance based on acts of domestic violence, dating violence, sexual assault, or
stalking against them. Despite the name of this law, VAWA protection is available to victims of domestic
violence, dating violence, sexual assault, and stalking, regardless of sex, gender identity, or sexual
orientation.
Use of This Optional Form: If you are seeking VAWA protections from your housing provider, your
housing provider may give you a written request that asks you to submit documentation about the incident
or incidents of domestic violence, dating violence, sexual assault, or stalking.
In response to this request, you or someone on your behalf may complete this optional form and submit it
to your housing provider, or you may submit one of the following types of third-party documentation:
(1) A document signed by you and an employee, agent, or volunteer of a victim service provider, an
attorney, or medical professional, or a mental health professional (collectively, “professional”) from
whom you have sought assistance relating to domestic violence, dating violence, sexual assault, or
stalking, or the effects of abuse. The document must specify, under penalty of perjury, that the
professional believes the incident or incidents of domestic violence, dating violence, sexual assault, or
stalking occurred and meet the definition of “domestic violence,” “dating violence,” “sexual assault,” or
“stalking” in HUD’s regulations at 24 CFR 5.2003. (2) A record of a Federal, State, tribal, territorial or local law enforcement agency, court, or
administrative agency; or (3) At the discretion of the housing provider, a statement or other evidence provided by the applicant or
tenant.
Submission of Documentation: The time period to submit documentation is 14 business days from the
date that you receive a written request from your housing provider asking that you provide documentation
of the occurrence of domestic violence, dating violence, sexual assault, or stalking. Your housing
provider may, but is not required to, extend the time period to submit the documentation, if you request an
extension of the time period. If the requested information is not received within 14 business days of when
you received the request for the documentation, or any extension of the date provided by your housing
provider, your housing provider does not need to grant you any of the VAWA protections. Distribution or
issuance of this form does not serve as a written request for certification.
Confidentiality: All information provided to your housing provider concerning the incident(s) of
domestic violence, dating violence, sexual assault, or stalking shall be kept confidential and such details
shall not be entered into any shared database. Employees of your housing provider are not to have access
to these details unless to grant or deny VAWA protections to you, and such employees may not disclose
this information to any other entity or individual, except to the extent that disclosure is: (i) consented to
2
Form HUD-5382
(06/2017)
by you in writing in a time-limited release; (ii) required for use in an eviction proceeding or hearing
regarding termination of assistance; or (iii) otherwise required by applicable law.
TO BE COMPLETED BY OR ON BEHALF OF THE VICTIM OF DOMESTIC VIOLENCE,
DATING VIOLENCE, SEXUAL ASSAULT, OR STALKING
1. Date the written request is received by victim: _________________________________________
2. Name of victim: ___________________________________________________________________
3. Your name (if different from victim’s):________________________________________________
4. Name(s) of other family member(s) listed on the lease:___________________________________
___________________________________________________________________________________
5. Residence of victim: ________________________________________________________________
6. Name of the accused perpetrator (if known and can be safely disclosed):____________________
__________________________________________________________________________________
7. Relationship of the accused perpetrator to the victim:___________________________________
8. Date(s) and times(s) of incident(s) (if known):___________________________________________
_________________________________________________________________
10. Location of incident(s):_____________________________________________________________
This is to certify that the information provided on this form is true and correct to the best of my knowledge
and recollection, and that the individual named above in Item 2 is or has been a victim of domestic violence,
dating violence, sexual assault, or stalking. I acknowledge that submission of false information could
jeopardize program eligibility and could be the basis for denial of admission, termination of assistance, or
eviction.
Signature __________________________________Signed on (Date) ___________________________
Public Reporting Burden: The public reporting burden for this collection of information is estimated to
average 1 hour per response. This includes the time for collecting, reviewing, and reporting the data. The
information provided is to be used by the housing provider to request certification that the applicant or
tenant is a victim of domestic violence, dating violence, sexual assault, or stalking. The information is
subject to the confidentiality requirements of VAWA. This agency may not collect this information, and
you are not required to complete this form, unless it displays a currently valid Office of Management and
Budget control number.
In your own words, briefly describe the incident(s):
______________________________________________________________________________________
______________________________________________________________________________________
City of Fort Worth, Texas
Mayor and Council Communication
DATE: 08/03/21 M&C FILE NUMBER: M&C 21-0522
LOG NAME: 19NS 2021-2022 ACTION PLAN
SUBJECT
(ALL) Conduct Public Hearing and Approve the City's 2021-2022 Annual Action Plan for the Use of Federal Grant Funds in the Amount of
$13,070,952.00 to be Awarded by the United States Department of Housing and Urban Development from the Community Development Block
Grant, HOME Investment Partnerships Program, Emergency Solutions Grant, and Housing Opportunities for Persons with AIDS Programs,
Authorize Collection and Use of Program Income, Authorize Execution of Related Contracts, Authorize the Use of Fee Waivers as HOME Match,
Adopt Attached Appropriation Ordinance, and Authorize Waiver of Indirect Costs
(PUBLIC HEARING - a. Report of City Staff: Sharon Burkley; b. Public Presentations; c. Council Action: Close Public Hearing and Act on the
M&C)
RECOMMENDATION:
It is recommended that City Council:
1. Conduct a public hearing to allow citizen input and consideration of the City's 2021-2022 Annual Action Plan for use of federal grant funds to
be awarded by the United States Department of Housing and Urban Development in the amount of $13,070,952.00 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 2021-2022 Annual 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 $75,000.00 of program income which is expected to result from activities using prior years'
Community Development Block Grant funds for the City's Priority Repair Program;
4. Authorize the collection and use of an estimated $75,000.00 of program income which is expected to result from activities using prior years'
HOME Investment Partnerships Program grant funds for the City's Homebuyer Assistance Program, and authorize the use of 10 percent of
the program income for administrative costs;
5. Authorize the City Manager or his designee to execute contracts for one year terms with the agencies listed in Tables 1, 2, and 3 below for
Program Year 2021-2022 for Community Development Block Grant, Emergency Solutions Grant, and Housing Opportunities for Persons
with AIDS grant funds, contingent upon receipt of funding, and satisfactory completion of all federal regulatory requirements;
6. Authorize the City Manager or his designee to extend the contracts for up to one year if an agency or department requests an extension and
such extension is necessary for completion of the program, or to amend the contracts 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;
7. Adopt the attached Appropriation Ordinance increasing the estimated receipts and appropriations to the Grants Operating Federal Fund in
the total amount of $13,070,952.00 consisting of $7,477,274.00 in Community Development Block Grant funds, $2,907,320.00 in HOME
Investment Partnerships Program grant funds, $632,124.00 in Emergency Solutions Grant funds, and $1,904,234.00 in Housing
Opportunities for Persons with AIDS grant funds, plus estimated program income in the amount of $150,000.00, all subject to receipt of such
funds; and
8. Authorize a waiver of the Neighborhood Services Department indirect cost rate of 18.73%, estimated total of $303,276.16.
DISCUSSION:
The City's 2021-2022 Annual Action Plan summarizes the major housing and community development activities and proposed expenditures for the
program year beginning October 1, 2021 and ending September 30, 2022 for use of federal grant funds totaling $13,070,952.00 from the United
States Department of Housing and Urban Development (HUD) 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.
It also summarizes the use of program income resulting from activities using prior years' CDBG and HOME funds, the primary purpose of which is
to benefit low-and moderate-income persons in Fort Worth. ESG funds primarily benefit homeless persons, and HOPWA funds primarily benefit
low- and moderate-income persons with HIV/AIDS.
Staff developed initial recommendations for the allocation of the estimated funding from HUD based on prior years' funding levels. Two public
hearings were held on April 14, 2021 and May 12, 2021 to provide citizens the opportunity to participate in the development of the Annual Action
Plan. Recommendations for award amounts were considered and adopted by the Community Development Council on May 12, 2021. These
funding recommendations were presented in City Council Work Session on June 22, 2021.
A 30-day public comment period was held from July 1, 2021 to July 30, 2021. Notice of this public comment period was published in the Wise
County Messenger and Glen Rose Reporter on June 25, 2021; in the Cleburne Times-Review, Hood County News, and Weatherford Democrat
on June 26, 2021; in the Fort Worth Star-Telegram on June 27, 2021; and in La Vida News on July 1, 2021.
TABLE 1: CDBG AGENCIES
Any comments received are maintained by the Neighborhood Services Department in accordance with federal regulations. The City held two
public hearings as part of the HUD required citizen participation process. The first public hearing was held by staff on July 14, 2021, and the
second public hearing is scheduled for the City Council meeting on August 3, 2021.
A summary of staff's final funding recommendations is provided below and in Tables 1, 2, and 3. A spreadsheet of funding recommendations is
also attached. The 2021-2022 Annual Action Plan will be submitted to HUD by August 15, 2021.
Indirect costs totaling approximately $354,132.42 could be charged to these grants, as the Neighborhood Services Department indirect cost rate
is 18.73% in the City's most recent Cost Allocation Plan. A waiver of these costs is requested to allow allocation of these funds to further support
the programs and services to assist low-to-moderate income citizens.
COMMUNITY DEVELOPMENT BLOCK GRANT
For Program Year 2021-2022, it is recommended that the amount of $7,477,274.00 in CDBG funds and an estimated amount of $75,000.00 in
CDBG program income totaling $7,522,274.00 be allocated as follows:
Public Services - $1,121,591.00: Includes social services for low- and moderate-income persons, persons with disabilities, and
disadvantaged persons
Housing Programs - $2,848,219.00: Includes funding for the City's Priority Repair Program, Cowtown Brush-Up, homebuyer and housing
services, accessibility modifications for seniors and persons with disabilities, and related project delivery costs for these programs
Major Projects - $2,012,009.00: Includes funding for Southside Community Center improvements, Bunche Park improvements, and
Street/Sidewalk improvements
Administration - $1,495,455.00: Includes costs for administering the CDBG grant, including allocations for the Financial Management
Services and Development Services Departments
Estimated Program Income - $75,000.00: Includes up to $75,000.00 in funding for the City's Priority Repair Program. Any CDBG program
income over the estimated amount not used for the Priority Repair Program will be allocated to priority activities in the City's Consolidated
Plan, subject to City Council approval.
HOME INVESTMENT PARTNERSHIPS PROGRAM
For Program Year 2021-2022, it is recommended that the amount of $2,907,320.00 in HOME funds and an estimated amount of $75,000.00 in
HOME program income totaling $2,982,320.00 be allocated as follows:
Homebuyer Assistance Program - $500,000.00: Includes funding for down payment and closing cost assistance for low- and moderate-
income homebuyer
Community Housing Development Organizations - $1,116,588.00: HUD requires that a minimum of 15 percent of HOME funds be allocated
to Community Housing Development Organizations (CHDOs) for affordable housing projects. These funds will be used by Housing Channel
for a multifamily rental demolition/reconstruction project in the Polytechnic neighborhood. The City is also authorized by HUD to fund CHDO
operating costs to support community-based affordable housing development. These funds for operating costs will be used by Housing
Channel to support completion of the multifamily rental demolition/reconstruction project. All housing developed with these funds will be sold
to homebuyers making at or below 80 percent of area median income (AMI), set by HUD.
Major Projects - $1,000,000.00: Includes funds allocated to the multifamily project to be developed by Fort Worth Housing Solutions (FWHS)
as a part of its Choice Neighborhood Initiative (CNI) grant.
Administration - $290,732.00: Includes costs for administering the HOME grant
Estimated Program Income - $75,000.00: Includes funding for the Homebuyer Assistance Program and HOME grant administrative costs.
HUD allows the City to use 10 percent of any HOME program income towards the cost of administering the HOME grant. HOME program
income over the estimated amount not used for the Homebuyer Assistance Program will be allocated to priority activities in the City's
Consolidated Plan, subject to City Council approval.
HOUSING OPPORTUNITIES FOR PERSONS WITH AIDS
For Program Year 2021-2022, it is recommended that the amount of $1,904,234.00 in HOPWA funds be allocated as follows:
Public Service Agencies - $1,148,627.00
Neighborhood Services Department/Community Action Partners - $698,480.00
Administration - $57,127.00
EMERGENCY SOLUTIONS GRANT
For Program Year 2021-2022, it is recommended that the amount of $632,124.00 in ESG funds be allocated as follows:
Public Service Agencies - $584,715.00
Administration - $47,409.00
CONTRACT RECOMMENDATIONS
The Community Development Council and Neighborhood Services Department staff recommend that contracts be executed with the listed
agencies for the amounts shown in the following tables.
Community Development Block Grant Contracts
AGENCY PROGRAM AMOUNT
AB Christian Learning Center After School Tutoring $85,000.00
AB Christian Learning Center Summer Reading Program $65,303.00
Artes de la Rosa Artes Academy $60,000.00
Big Brothers Big Sisters Lone Star Mentor 2.0 @ Young Men's Leadership
Academy $50,000.00
Big Brothers Big Sisters Lone Star Mentor 2.0 @ Young Women's Leadership
Academy $50,000.00
Boys & Girls Clubs of Greater Tarrant County, Inc.After School Program $60,000.00
United Community Centers, Inc.Educational Enrichment $100,000.00
Family Pathfinders of Tarrant County Financial Capability Program $50,000.00
The Ladder Alliance Computer Skills Training $70,000.00
Housing Channel Homebuyer Education and Housing
Counseling Services $125,000.00
Meals-On-Wheels, Inc. of Tarrant County Home-Delivered Meals $116,288.00
Guardianship Services, Inc.Financial Exploitation Prevention Center $70,000.00
The Presbyterian Night Shelter of Tarrant County,
Inc.Case Management for Homeless $145,000.00
The Salvation Army Red Shield Emergency Shelter $75,000.00
CDBG Public Service Agencies Total $1,121,591.00
Rehabilitation, Education and Advocacy for
Citizens with Handicaps DBA REACH, Inc.
Accessibility Improvements for Low
Income Residents $115,000.00
Fort Worth Area Habitat for Humanity, Inc. DBA
Trinity Habitat for Humanity Cowtown Brush Up Paint Program $455,000.00
Fort Worth Area Habitat for Humanity, Inc. DBA
Trinity Habitat for Humanity
Preserve-A-Home Program (Como
Neighborhood Improvement Strategy)$400,000.00
CDBG Subrecipient Agencies Total $970,000.00
TOTAL CDBG CONTRACTS $2,091,591.00
TABLE 2: HOPWA AGENCIES
AGENCY PROGRAM AMOUNT
Tarrant County
Samaritan Housing, Inc.
Supportive Services; Facility-Based Housing Operations; Tenant-
Based Rental Assistance; Administration $845,765.00
AIDS Outreach Center,
Inc.*
Short-Term Rent, Mortgage, and Utility Assistance; Supportive
Services; Administration $302,862.00
TOTAL HOPWA CONTRACTS $1,148,627.00
Housing Opportunities for Persons With AIDS Contracts
*The City has identified a potential conflict of interest under the HOPWA Regulations related to this award and is in the process of seeking a
waiver of the conflict of interest from HUD. A contract will not be executed with AIDS Outreach Center, Inc. unless and until the City receives
approval from HUD. In the event the City does not receive approval, an amended Action Plan will be submitted, as necessary, to address the
reallocation of the funds.
Emergency Solutions Grant Contracts
TABLE 3: ESG AGENCIES
AGENCY PROGRAM AMOUNT
The Presbyterian Night Shelter of Tarrant County, Inc.Shelter Operations/Services $130,315.00
Lighthouse for the Homeless DBA True Worth Place Shelter Operations/Services $177,000.00
The Salvation Army Homelessness Prevention $106,440.00
Center for Transforming Lives Rapid Re-Housing $100,000.00
SafeHaven of Tarrant County Shelter Operations/Services $70,960.00
TOTAL ESG CONTRACTS $584,715.00
All figures have been rounded to the nearest dollar for presentation purposes. These programs are available in ALL COUNCIL DISTRICTS.
FISCAL INFORMATION / CERTIFICATION:
The Director of Finance certifies that upon approval of the above recommendations and adoption of the attached appropriation ordinance, funds
will be available in the current operating budget, as appropriated, in the Grants Operating Federal Fund. The Neighborhood Services Department
(and Financial Management Services) will be responsible for the collection and deposit of funds due to the City. Prior to an expenditure being
incurred, the Neighborhood Services Department has the responsibility to validate the availability of funds. This is a reimbursement grant.
Submitted for City Manager's Office by: Fernando Costa 6122
Originating Business Unit Head:Victor Turner 8187
Additional Information Contact:Sharon Burkley 5785
Sean Stanton 5811