HomeMy WebLinkAboutContract 47281-A1 CITY SECRETARY
CONMCT NO.
FIRST AMENDMENT TO CITY SECRETARY CONTRACT NO. 47281
WHEREAS, the City of Fort Worth ("City") and AIDS Outreach Center, Inc. ("Agency")
made and entered into City Secretary Contract No. 47281 ("Contract");
WHEREAS, the Contract provides funding to Agency pursuant to a grant received by
City from the United States Department of Housing and Urban Development ("HUD") through
the Housing Opportunities for Persons with AIDS Program ("HOPWA");
WHEREAS, the Agency provides supportive services including case management and
housing assistance to HOPWA Eligible Clients and has requested additional HOPWA Funds for
Short Term Rent, Mortgage and Utility Assistance ("STRMU");
WHEREAS, it is the mutual desire of City and Agency to amend the Contract to add an
additional $72,000.00 of HOPWA Funds for a total Contract amount of$624,027.00 in order to
complete the Program and meet Contract objectives;
WHEREAS, Exhibit "B" - Budget contains a line item for a Case Manager, and the
Agency has changed the position title to Housing Coordinator; and
WHEREAS, it is the mutual desire of the City and Agency to amend the contract to meet
Contract objectives.
NOW, THEREFORE, City and Agency hereby agree to amend the Contract as follows:
1.
Section 4.1 Provide HOPWA Funds is amended to read as follows:
"City shall provide up to $624,027.00 of HOPWA Funds under the terms
and conditions of this Contract."
II.
Section 9.2.2.2 is amended to read as follows:
"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, notwithstanding the following:
Agency may not submit additional STRMU invoices for
reimbursement that include expenses dated before January 1, 2016."
OFFICIAL RECORD
CITY SECRETARY
G` OF S� �AR� FT.WORTH, TX
G�
Amendment No. 1 to CSC No.47281 Page 1
AIDS Outreach Center, Inc. (HOPWA) Rev. 4/2016
III.
Section 9.2.4 Overview Report is amended to read as follows:
"9.2.4 Agency shall submit the Overview Report, attached hereto as
EXHIBIT "H" — Overview Report, quarterly after City has informed
the Agency that all Reimbursement Requests for that quarter have
been paid. Once notified, Agency shall have 30 calendar days to
submit the Overview Report. For quarters 1, 2, and 3, Agency must
submit Parts 3 through 7 for the Overview Report. For quarter 4,
Agency must submit parts 1 through 7 of the report. A paper copy
must be submitted and an electronic copy must also be emailed to
Asan fortwo rthtexas.j!ov."
IV.
Section 17 INSURANCE AND BONDING is amended to read as follows:
"Agency will maintain coverage in the form of insurance or bond in the amount of
$624,027.00 to insure against loss from the fraud, theft or dishonesty of any of
Agency's officers, agents, trustees, directors or employees."
V.
EXHIBIT "A" — PROGRAM SUMMARY, EXHIBIT "B" — BUDGET, and
EXHIBIT "D" — REIMBURSEMENT FORMS, Attachment II — Expenditure Worksheet
and Attachment III — Client Data Report, attached to the Contract are hereby replaced with
the attached EXHIBIT "A" PROGRAM SUMMARY Revised 04/2016, EXHIBIT "B" —
BUDGET Revised 04/2016 and EXHIBIT "D" — REIMBURSEMENT FORMS,
Attachment II—Expenditure Worksheet Revised 04/2016 and Attachment III— Client Data
Report Revised 04/2016.
V1.
This amendment is effective as of the Effective Date of the Contract.
VII.
All terms and conditions of the Contract not amended herein remain unaffected and in full force
and effect, are binding on the Parties and are hereby ratified by the Parties. Capitalized terms not
defined herein shall have the meanings assigned to them in the Contract.
[SIGNATURES APPEAR ON FOLLOWING PAGE]
Amendment No. I to CSC No.47281 Page 2
AIDS Outreach Center, Inc.(HOPWA) Rev.4/2016
AIDS OUTREACH CENTER, INC. EXHIBIT "A"
Supportive Services, STRMU, and TBRA PROGRAM SUMMARY
Revised 04/2016
PROGRAM SUMMARY
(HOPWA)
October 1, 2015 to September 30, 2016 $624,027.00
PERIOD AMOUNT
Capitalized terms not defined herein shall have meanings assigned them in the Contract.
PROGRAM:
The Program provides HOPWA Eligible Clients with one or more of the following:
1) supportive services;
2) tenant based rental assistance ("TBRA"); and/or,
3) short-term rental, mortgage, or utility assistance ("STRMU").
Supportive Services includes housing counseling and case management, including the
development of housing plans.
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 AOC case manager.
STRMU includes short term assistance for up to 21 weeks. STRMU provides assistance with
utilities, rent, or mortgage payments and must not exceed a client's current monthly budget
deficit caused by an unavoidable, unplanned, documented emergency consistent with HUD
guidelines and AOC's local policy. Clients receiving other government housing assistance are
not eligible.
Agency's office and Program services will be available at 400 N. Beach Street, Suite 100, Fort
Worth, TX 76111, Monday through Thursday 8:30 a.m. to 5:00 p.m. and Friday, 8:30 a.m. to
4:00 p.m.
The Program will serve HOPWA Eligible Clients in Tarrant, Johnson, Parker, Wise, Hood and
Somervell counties.
HOPWA Funds will pay for direct assistance such as TBRA and STRMU. HOPWA Funds will
also be used to pay costs associated with delivering supportive services to any client receiving
either TBRA or STRMU assistance, including salaries, fringe benefits, and FICA for employees,
supplies, insurance, and Program facility rent and utility costs. HOPWA Funds will also pay for
contracted labor services that include accounting and security services. No more than 7% of the
Amendment No. 1 to CSC No.47281 Page 4
AIDS Outreach Center, Inc. (HOPWA) Rev.4/2016
HOPWA Funds will be used to pay administrative costs, including salaries, insurance, taxes, and
legal and accounting fees associated with the Program.
REGULATORY CLASSIFICATION:
IDIS matrix Code(s) and Service Category: 3 1 D HOPWA Project Sponsor Administration 3 1 C
HOPWA Project Sponsor Activity
Regulatory Citation(s): 24 CFR 574.300(b)(10)—Administrative Expenses
24 CFR 574.300(b)(7)— Supportive Services
24 CFR 574.300(b)(6)— STRMU
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 Contract Performance Outcome: The Program must provide services to a
minimum of 125 Unduplicated Clients. The Program must provide TBRA services to a
minimum of 57 Unduplicated Clients and must provide STRMU services to a minimum of 68
Unduplicated Clients. Unduplicated Clients must be residents of Tarrant, Johnson, Parker, Wise,
Hood or Somervell counties as shown by the monthly reports on Attachment 111.
Amendment No. 1 to CSC No.47281 Page 5
AIDS Outreach Center, Inc. (HOPWA) Rev.4/2016
EXHIBIT "B"-BUDGET Revised 04/2016
AIDS OUTREACH CENTER, INC.
Account Gra t AB C TOTAL
ADMINISTRATIVE(HOPWA ONLY)
Salaries 1001 5,735 2,200 106,768 114,703
FICA 1002 439 167 1,448 2,054
Life Insurance 1003
Health Insurance 1004 367 190 1,760 2,317
Disability Insurance 1005
Unemployment-State 1006 89 12 137 238
Contract Labor-Accounting 1007
TOTAL ADMINISTRATIVE 6,630 2,569 110,113 119,312
EXPENSES
SUPPORTIVE SERVICE
PROGRAM PERSONNEL
Salaries 2001 50,407 123,378 75,358 249,143
FICA 2002 3,856 9,438 1,652 14,946
Life Insurance 2003
Health Insurance 2004 3,000 18,676 21,676
Unemployment 2005 724 1604 2,328
Worker's Compensation 2006
Retirement 2007
SUPPLIES AND SERVICES
Office Supplies 3001 925 510 17,065 18,500
Office Equipment Rental 3002 400 925 6,675 8,000
Postage 3003 50 330 620 1,000
Printing 3004 50 325 625 1,000
MISCELLANEOUS
Construction/Building Materials 4001
(only REACH)
Contract Labor-Accounting(City
needs copy of contract before expenses 4002 2,500 3,135 44,365 50,000
can be reimbursed)
Contract Labor-IT(City needs
copy of contract before expenses can be 4003 2,500 3,000 5,405 10,905
reimbursed)
Field Trip Admission Expenses 4004
Other Field Trip Expenses (if 4005
preapproved by City)
Food Supplies 4006
Teaching Aids 4007
Amendment No. 1 to CSC No.47281 Page 6
AIDS Outreach Center,Inc.(HOPWA) Rev.4/2016
FACILITY AND UTILITIES
Telephone 5001 625 250 11,625 12,500
Electric 5002 800 700 14,500 16,000
Gas 5003 200 125 3,675 4,000
Water and Wastewater 5004 200 250 3,550 4,000
Solid Waste Disposal 5005
Rent(City needs copy of lease 5006 4,200 3,142 76,658 84,000
before expenses can be reimbursed
Custodial Services 5007 650 450 11,900 13,000
Repairs 5008 0 575 0 575
Cleaning Supplies 5009
Building Security 5010
LEGAL,FINANCIAL,AND
INSURANCE
Fidelity Bond or Equivalent 6001
Directors and Officers 6002
General Commercial Liability 6003 100 800 1,100 2,000
Contract Accounting-Audit 6005
Requirements
TOTAL SUPPORTIVE SERVICE
71,187 167,613 274,773 513,573
EXPENSES
DIRECT ASSISTANCE
Childcare Scholarships 7001
DIRECT ASSISTANCE-STRMU
Short-term Rent Assistance 7002 80,000 80,000
Short-term Mortgage Assistance 7003 8,210 8,210
Short-term Utilities Assistance 7004 14,000 14,000
TOTAL STRMU EXPENSES 102,210 102,210
DIRECT ASSISTANCE-TBRA
Tenant Based Rental Assistance 7005 444,000 444,000
TOTAL TBRA EXPENSES 444,000 444,000
BUDGET TOTAL 624,027 170,182 384,886 1,179,095
FUNDING A: Tarrant County Pass Through
FUNDING B: Other Funding
FUNDING C:N/A
Amendment No. 1 to CSC No.47281 Page 7
AIDS Outreach Center,Inc.(HOPWA) Rev.4/2016
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 Revised 04/2016. 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 Revised 04/2016 is June 1,2016.
SALARY DETAIL—ADMINISTRATIVE
Position Name Rate Annual Hours Est.Percent to Amount to Grant
Grant
Receptionist 25,480 2080 5% 1,274
Director of Administrative 52,984 2080 5% 2,649
Services
Accountant 36,239 2080 5% 1,812
TOTAL 114,703 5% 5,735
FRINGE DETAIL—ADMINISTRATIVE
Percent of Amount Est.Percent to Amount to Grant
Payroll Grant
FICA 7.65% 2,054 21% 439
Life Insurance
Health Insurance 6.40% 2,317 16% 367
Disability Insurance
Unemployment 1.55% 238 37% 89
Retirement
TOTAL 4,609 19% 895
MISCELLANEOUS—ADMINISTRATIVE
Total Budget Est.Percent to Amount to Grant
Grant
Contract Labor—Accounting 0
TOTAL ` 0
SALARY DETAIL—SUPPORTIVE SERVICES
Position Name Rate Annual Hours Est.Percent to Amount to Grant
Grant
DIRECTOR CASE MGMT 56,143 2080 5% 2,807
HOUSING COORDINATOR 41,000 2080 98% 40,000
ASSOC EXEC DIRECTOR 61,000 2080 5% 3,050
CASE MANAGER 30,000 2080 5% 1,500
Amendment No. 1 to CSC No.47281 Page 8
AIDS Outreach Center,Inc.(HOPWA) Rev.4/2016
CASE MANAGER 31,000 2080 5% 1,550
CASE MANAGER 30,000 2080 5% 1,500
TOTAL 249,143 20% 50,407
FRINGE DETAIL—SUPPORTIVE SERVICES
Percent of Est. Percent to
Amount Amount to Grant
Payroll Grant
FICA 7.65% 14,946 26% 3,856
Life Insurance
Health Insurance 5.94% 21,676 14% 3,000
Unemployment 1.44% 2,328 31% 724
Disability Insurance
Workers Compensation
Retirement
TOTAL 38,950 19% 7,580
SUPPLIES AND SERVICES—SUPPORTIVE SERVICES
Total Budget Est.Percent to Amount to Grant
Grant
Office Supplies 18,500 5% 925
Office Equipment Rental 8,000 5% 400
Postage 1,000 5% 50
Printing 1,000 5% 50
TOTAL 28,500 5% 1,425
MISCELLANEOUS—SUPPORTIVE SERVICES
Total Budget Est. Percent to Amount to Grant
Grant
Contract Labor—IT 10,905 23% 2,500
Contract Labor—Accounting 50,000 5% 2,500
Craft Supplies
Facility Fees
Field Trip Costs
Food Supplies
Teaching Aids
TOTAL 60,905 8% 5,000
Amendment No. 1 to CSC No.47281 Page 9
AIDS Outreach Center, Inc. (HOPWA) Rev.4/2016
FACILITY AND UTILITIES—SUPPORTIVE SERVICES
Total Budget Est.Percent to Amount to Grant
Grant
Telephone 12,500 5% 625
Electric 16,000 5% 800
Gas 4,000 5% 200
Water and Wastewater 4,000 5% 200
Solid Waste Disposal
Rent 84,000 5% 4,200
Custodial Services 13,000 5% 650
Repairs 575 0
Building Security
TOTAL 134,075 5% 6,675
LEGAL, FINANCIAL AND INSURANCE
Total Budget Est.Percent to Amount to Grant
Grant
Fidelity Bond(or Equivalent)
General Commercial Liability 2,000 5% 100
Directors and Officers
Contract Accounting—Audit Requirements
TOTAL 2,000 5% 100
DIRECT ASSISTANCE—STRMU
Total Budget Est. Percent to Amount to Grant
Grant
Short-Term Rent Assistance 80,000 100% 80,000
Short Term Mortgage Assistance 8,210 100% 8,210
Short Term Utilities Assistance 14,000 100% 14,000
TOTAL 102,210 100% 102,210
DIRECT ASSISTANCE—TBRA
Total Budget Est. Percent to Amount to Grant
Grant
Tenant Based Rental Assistance 444,000 100% 444,000
TOTAL 444,000 100% 444,000
Amendment No. 1 to CSC No.47281 Page 10
AIDS Outreach Center,Inc. (HOPWA) Rev.4/2016
EXHIBIT "D"—REIMBURSEMENT FORMS
AIDS OUTREACH CENTER, INC.
Amendment No. 1 to CSC No.47281 Page I I
AIDS Outreach Center, Inc. (HOPWA) Rev.4/2016
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Amendment No. 1 to CSC No.47281 Page 13
AIDS Outreach Center,Inc.(HOPWA) Rev.4/2016
EXHIBIT"H"
OVERVIEW REPORT
AIDS OUTREACH CENTER, INC.
Amendment No. 1 to CSC No.47281 Page 14
AIDS Outreach Center, Inc. (HOPWA) Rev.4/2016
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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 form HUD-40110-D(Expiration Date:10/31/2017
Overview. The Consolidated Annual Performance and Evaluation Report Assistance,Housing Relocation&Stabilization Services,Employment,
(CAPER)provides annual performance reporting on client outputs and Education,General Health Status,,Pregnancy Status,Reasons for Leaving,
outcomes that enables an assessment of grantee performance in achieving the Veteran's Information,and Children's Education. Other HOPWA projects
housing stability outcome measure. The CAPER,in conjunction with the sponsors ma} also benefit from collecting these data elements.
Integrated Disbursement Information System(IDIS),fulfills statutory and
regulatory program reporting requirements and provides the grantee and
Final Assembly of Report. After the entire report is assembled,please
HUD with the necessary information to assess the overall program
performance and accomplishments against planned goals and objectives. number each page sequentially.
Filing Requirements. Within 90 days of the completion of each program
HOPWA formula grantees are required to submit a CAPER,and complete
year,grantees must submit their completed CAPER to the CPD Director in
annual performance information for all activities undertaken during each
program year in the IDIS,demonstrating coordination with other the grantee's State or Local HUD Field Office,and to the HOPWA Program
Consolidated Plan resources. HUD uses the CAPER and IDIS data to obtain Office:at HOPNA'A ci hud.gov. Electronic submission to HOPWA Program
office is preferred)however, electronic submission is not possible,hard
essential information on grant activities,project sponsors,Subrecipient copies can be mail
organizations,housing sites,units and households,and beneficiaries(which ed to:Office of HIV/AIDS Housing,Room 7212,U.S.
includes racial and ethnic data on program participants). The Consolidated Department of Housing and Urban Development,451 Seventh Street,
t,SW,
Plan Management Process tool(CPMP)provides an optional tool to integrate Washington,D.C.
the reporting of HOPWA specific activities with other planning and reporting
on Consolidated Plan activities. Record Keeping. Names and other individual information must be kept
confidential,as required by 24 CFR 574.440. However,HUD reserves the
Table of Contents right to review the information used to complete this report for grants
management oversight purposes,except for recording any names and other
PART 1:Grantee Executive Summary identifying information. In the case that HUD must review client level
1.Grantee Information data,no client names or identifying information will be retained or
2.Project Sponsor Information recorded. Information is reported in aggregate to HUD without
3.Administrative Subrecipient Information personal identification.Do not submit client or personal information in
4.Program Subrecipient Information data systems to HUD.
5.Grantee Narrative and Performance Assessment
a.Grantee and Community Overview
b.Annual Performance under the Action Plan Definitions
c.Barriers or Trends Overview Adjustment for Duplication: Enables the calculation of unduplicated
d.Assessment of Unmet Housing Needs output totals by accounting for the total number of households or units that
PART 2:Sources of Leveraging and Program Income received more than one type of HOPWA assistance in a given service
1. Sources of Leveraging category such as HOPWA Subsidy Assistance or Supportive Services.For
2. Program Income and Resident Rent Payments example,if a client household received both TBRA and STRMU during the
PART 3:Accomplishment Data:Planned Goals and Actual Outputs operating year,report that household in the category of HOPWA Housing
PART 4•Summary of Performance Outcomes Subsidy Assistance in Part 3,Chart 1,Column[Ib]in the following manner:
1.Housing Stability: Permanent Housing and Related Facilities
2.Prevention of Homelessness: Short-Term Housing Payments [11 Outputs'
3.Access to Care and Support: Housing Subsidy Assistance with HOPWA Housing Subsidy
Supportive ServicesNumber of
PART 5:R'orksheet-Determining Housing Stability Outcomes Assistance Households
PART 6:Annual Certification of Continued Use for HOPNVA Facility-
Based Stewardship Units(Only) 1. Tenant-Based Rental Assistance I
PART 7:Summary Overview of Grant Activities Permanent Housing Facilities:
A.Information on Individuals,Beneficiaries and Households Receiving 2a. Received Operating
HOPWA Housing Subsidy Assistance(TBRA,STRMU.PHP,Faciliq' Subsidies/Leased units
Based Units,Master Leased Units ONLY)
B.Facility-Based Housing Assistance Transitional/Short-term Facilities:
2b. Received Operating Subsidies
Continued Use Periods. Grantees that received HOPWA funding for new
construction,acquisition,or substantial rehabilitations are required to operate Permanent Housing Facilities:
their facilities for HOPWA-eligible beneficiaries for a ten(10)years period. 3a Capital Development Projects placed
If no further HOPWA funds are used to support the facility,in place of in service during the operating year
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 Transitional/Short-term Facilities:
period is three(3)years if the rehabilitation is non-substantial. 3b Capital Development Projects placed
in service during the operating year
In connection with the development of the Department's standards for
Homeless Management Information Systems(HMIS),universal data Short-term Rent,Mortgage,and
elements are being collected for clients of HOPWA-funded homeless 4. Utility Assistance 1
assistance projects. These project sponsor/subrecipient records would Adjustment for duplication
include:Name,Social Security Number,Date of Birth,Ethnicity and Race, �. 1
Gender,Veteran Status,Disabling Conditions,Residence Prior to Program (subtract)
Entry,Zip Code of Last Permanent Address,Housing Status.Program Entry TOTAL Housing Subsidy
Date,Program Exit Date,Personal Identification Number,and Household 6. Assistance(Sum of Rows 1-4 minus I
Identification Number. These are intended to match the elements under Row 5)
HMIS.The HOPWA program-level data elements include: Income and
Sources,Non-Cash Benefits,HIV/AIDS Status,Services Provided,and
Housing Status or Destination at the end of the operating year. Other
suggested but optional elements are:Physical Disability,Developmental
Disability,Chronic Health Condition,Mental Health,Substance Abuse,
Domestic Violence,Date of Contact,Date of Engagement,Financial
Previous editions are obsolete Page i form HITD-40110-D(Expiration Date: 10/31/2017)
Administrative Costs: Costs for general management,oversight, "grassroots."
coordination,evaluation,and reporting. By statute,grantee administrative
costs are limited to 3%of total grant award,to be expended over the life of HOPWA Eligible Individual: The one(1)low-income person with
the grant. Project sponsor administrative costs are limited to 7°0 of the HIV/AIDS who qualifies a household for HOPWA assistance.This person
portion of the grant amount they receive. may be considered"Head of Household.'When the CAPER asks for
information on eligible individuals,report on this individual person only.
Beneficiary(ies):All members of a household who received HOPWA Where there is more than one person with HIV/AIDS in the household,the
assistance during the operating year including the one individual who additional PWH/A(s),would be considered a beneficiary(s).
qualified the household for HOPWA assistance as well as am other
members of the household(with or without HIV)who benefitted from the HOPWA Housing Information Services: Services dedicated to helping
assistance. persons living with HIV/AIDS and their families to identify,locate,and
acquire housing.This may also include fair housing counseling for eligible
Central Contractor Registration(CCR): The primary registrant persons who may encounter discrimination based on race,color,religion,
database for the U.S.Federal Govemment.CCR collects,validates,stores. sex,age,national origin,familial status,or handicap/disability.
and disseminates data in support of agency acquisition missions,including
Federal agency contract and assistance awards. Both current and potential HOPWA Housing Subsidy Assistance Total: The unduplicated number
federal govemment registrants(grantees)are required to register in CCR of households receiving housing subsidies(TBRA.STRMU,Permanent
in order to be awarded contracts by the federal govemment.Registrants Housing Placement services and Master Leasing)and/or residing in units
must update or renew their registration at least once per year to maintain of facilities dedicated to persons living with HIV/AIDS and their families
an active status.Although recipients of direct federal contracts and grant and supported with HOPWA funds during the operating year.
awards have been required to be registered with CCR since 2003,this
requirement is now being extended to indirect recipients of federal funds Household: A single individual or a family composed of two or more
with the passage of ARRA(American Recovery and Reinvestment Act). persons for which household incomes are used to determine eligibility and
Per ARRA and FFATA(Federal Funding Accountability and for calculation of the resident rent payment. The term is used for
Transparency Act)federal regulations,all grantees and sub-grantees or collecting data on changes in income,changes in access to services,receipt
subcontractors receiving federal grant awards or contracts must have a of housing information services,and outcomes on achieving housing
DUNS(Data Universal Numbering System)Number. stability. Live-In Aides(see definition for Live-In Aide)and non-
beneficiaries(e.g.a shared housing arrangement with a roommate)who
Chronically Homeless Person:An individual or family who:(i)is resided in the unit are not reported on in the CAPER.
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 Housing Stability: The degree to which the HOPWA project assisted
in an emergency shelter,(ii)has been homeless and living or residing in a beneficiaries to remain in stable housing during the operating year. See
place not meant for human habitation,a safe haven,or in an emergency Part 5:Determining Housing Stability Outcomes for definitions of stable
shelter continuously for at least I year or on at least 4 separate occasions in and unstable housing situations.
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 In-kind Leveraged Resources: These involve additional types of support
substance use disorder,serious mental illness,developmental disability(as provided to assist HOPWA beneficiaries such as volunteer services,
defined in section 102 of the Developmental Disabilities Assistance and materials,use of equipment and building space. The actual value of the
Bill of Rights Act of 2000(42 U.S.C. 15002)),post traumatic stress
support can be the contribution of professional services,based on
disorder,cognitive impairments resulting from a brain injury,or chronic
physical illness or disability,including the co-occurrence of 2 or more of customary rates for this specialized support,or actual costs contributed
those conditions.Additionally,the statutory definition includeas from other leveraged resources. In determining a rate for the contribution
chronically homeless a person who currently lives or resides as of volunteer time and services,use the rate established in HUD notices,
such as the rate often dollars per hour. The value
institutional care facility,including a jail,substance abuse or mental health any donated material,
at
treatment facility,hospital or other similar facility,and has resided there time
equipment,building,or lease should based e thee fair market value
for fewer than 90 days if such person met the other criteria for homeless tme of donation. Related documentattion can bhe from recent bills of sall
es.
prior to entering that facility. See 42 U.S.C. l 1360 2 [his does not advertised prices,appraisals,or other information for comparable proper
p g y ( ( )) similarly situated.
include doubled-up or overcrowding situations.
Disabling Condition: Evidencing a diagnosable substance use disorder, Leveraged Funds: The amount of funds expended during the operating
serious mental illness,developmental disability,chronic physical illness, year from non-HOPWA federal,state,local,and private sources by
or disability,including the co-occurrence of 0,vo or more of these grantees or sponsors in dedicating assistance to this client population.
conditions. In addition,a disabling condition may limit an individual's Leveraged funds or other assistance are used directly in or in support of
ability to work or perform one or more activities of daily living.An HOPWA program delivery.
HIV/AIDS diagnosis is considered a disabling condition.
Facility-Based Housing Assistance: All eligible HOPWA Housing Live-In Aide: A person who resides with the HOPWA Eligible Individual
expenditures for or associated with supporting facilities including y and who meets the following criteria: (I)is essential to the care and well-
community residences,SRO dwellings,short-term facilities,project-based being of the person;(2)is not obligated for the support of the person;and
rental units,master leased units,and other housing facilities approved by (3)would not be living in the unit except to provide the necessary
HUD. supportive services. See the Code of Federal Regulations Title 24, Part
5.403 and the HOP TVA Grantee Oversight Resource Guide for additional
Faith-Based Organization: Religious organizations of three types:(1) reference.
congregations:(2)national networks,which include national
denominations,their social service arms(for example,Catholic Charities, blaster Leasing:Applies to a nonprofit or public agency that leases units
Lutheran Social Services),and networks of related organizations(such as of housing(scattered-sites or entire buildings)from a landlord,and
YMCA and YWCA);and(3)freestanding religious organizations,which subleases the units to homeless or low-income tenants.By assuming the
are incorporated separately from congregations and national networks. 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
Grassroots Organization: An organization headquartered in the local of sufficient income.
community where it provides services;has a social services budget of
$300,000 or less annually,and six or fewer full-time equivalent Operating Costs: Applies to facility-based housing only,for facilities
employees. Local affiliates of national organizations are not considered that are currently open. Operating costs can include day-to-day housing
Previous editions are obsolete Page ii form HUD-40110-D(Expiration Date: 10/31/2017)
function and operation costs like utilities,maintenance,equipment, Subrecipient Organization: An} organization that receives funds from a
insurance,security,furnishings,supplies and salary for staff costs directly project sponsor to provide eligible housing and other support services
related to the housing project but not staff costs for delivering services. and/or administrative services as defined in 24 CFR 574.300. If a
Subrecipient organization provides housing and/or other supportive
Outcome: The degree to which the HOPWA assisted household has been services directly to clients,the Subrecipient organization must provide
enabled to establish or maintain a stable living environment in housing that performance data on household served and funds expended. Funding
is safe,decent,and sanitary,(per the regulations at 24 CFR 574310(b)) flows to subrecipients as follows:
and to reduce the risks of homelessness,and improve access to HIV
treatment and other health care and support. HUD Funding --->Grantee --> Project Sponsor— Subrecipient
Output: The number of units of housing or households that receive Tenant-Based Rental Assistance(TBRA): TBRA is a rental subsidy
HOPWA assistance during the operating year. program similar to the Housing Choice Voucher program that grantees can
provide to help low-income households access affordable housing. The
Permanent Housing Placement: A supportive housing service that helps TBRA voucher is not tied to a specific unit,so tenants may move to a
establish the household in the housing unit,including but not limited to different unit without losing their assistance,subject to individual program
reasonable costs for security deposits not to exceed two months of rent rules. The subsidy amount is determined in part based on household
costs. income and rental costs associated with the tenants lease.
Program Income: Gross income directly generated from the use of Transgender: Transgender is defined as a person who identifies with,or
HOPWA funds,including repayments. See grant administration presents as,a gender that is different from his/her gender at birth.
requirements on program income for state and local governments at 24
CFR 85.25,or for non-profits at 24 CFR 84.24. 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'
Project-Based Rental Assistance(PBRA): A rental subsidy program reserves or the National Guard unless the person was called up to active
that is tied to specific facilities or units owned or controlled b} a project duty.
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(STRRIU)Assistance: A
time-limited,housing subsidy assistance designed to prevent homelessness
and increase housing stability. Grantees may provide assistance for up to
21 weeks in any 52 week period. The amount of assistance varies per
client depending on funds available,tenant need and program guidelines.
Stewardship Units: Units developed with HOPWA,where HOPWA
funds were used for acquisition,new construction and rehabilitation that
no longer receive operating subsidies from HOPWA. Report information
for the units is subject to the three-year use agreement if rehabilitation is
non-substantial and to the ten-year use agreement if rehabilitation is
substantial.
Previous editions are obsolete Page iii form HUD-401 10-D(Expiration Date: 10/31/2017)
Housing Opportunities for Person with AIDS (HOPWA)
Consolidated Annual Performance and Evaluation Report (CAPER)
Measuring Performance Outputs and Outcomes
OMB Number 2506-0133(Expiration Date: 10/31/2017)
Part 1: Grantee Executive Summary
As applicable,complete the charts below to provide more detailed information about the agencies and organizations responsible
for the administration and implementation of the HOPWA program.Chart 1 requests general Grantee Information and Chart 2 is
to be completed for each organization selected or designated as a project sponsor,as defined by CFR 574.3. In Chart 3, indicate
each subrecipient organization with a contract/agreement of$25,000 or greater that assists grantees or project sponsors carrying
out their administrative or evaluation activities. In Chart 4,indicate each subrecipient organization with a 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 arty 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 IN
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 Cities: Counties:
Area(s)
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.
Previous editions are obsolete Page 1 form HUD-40110-D(Expiration Date:1.0/31/2017)
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 elements
address requirements in the Federal Financial Accountability and Transparency Act of 2006 (Public Law 109-282).
Note: Please see the definitions for distinctions between project sponsor and subrecipient.
Note: If ant°information does not apph,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 Fax Number(with area code)
Tax Identification Number(TIN)
DUN&Bradstreet Number(DUNS):
Congressional District of Project Sponsor's
Business Address
Congressional District(s)of Primary Service
Area(s)
City(ies)and County(ies)of Primary Service Cities: Counties:
Area(s)
Total HOPWA contract amount for this
Organization for the operating ear
Organization's website Address
Is the sponsor a nonprofit organization? ❑ Yes ❑No Does your organization maintain a waiting list? ❑ Yes ❑No
Please check ifves and a faith-based or,Qani_ation. ❑
Please check if}es and a grassroots organi anon. 17-1If yes,explain in the narrative section hose this list is administered.
Previous editions are obsolete Page 2 form 1111D-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 forms of financial assistance; and contracts,
subcontracts,purchase orders,task orders, and delivery orders. (Organizations listed may have contracts with project sponsors)
These elements address requirements in the Federal Funding and Accountability and Transparency Act of 2006(Public Law 109-
282).
Note:Please see the definitions for distinctions between prgiect sponsor and subrecipient.
Note:If any information does not appl}'to your organization,please enter N/A.
Subrecipient Name Parent Company Name,ifappticable
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)
DCN&Bradstreet Number(DCiNs):
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 Cities: Counties:
Area(s)
Total IIOPWA Subcontract Amount of this
Organization for the operating year
Previous editions are obsolete Page 3 form IIUD-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 maty include:grants, sub-grants, loans, awards, cooperative agreements, and other forms
of financial assistance; and contracts, subcontracts,purchase orders, task orders, and delivery orders.
Note: If any 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
Cit}',Count},State,Zip
Fax Number(include area code)
Phone Number(included area code)
Employer Identification Number(EIN)or
Tax Identification Number(TIN)
DUN&Bradstreet Number(DUNs)
North American Industry Classification
System(NAICS)Code
Congressional District of the Sub-recipient's
Business Address
Congressional District(s)of Primary Service
Area
City(ies)and County(ies)of Primary Service Cities: Counties:
Area
Total HOPWA Subcontract Amount of this
Organization for the operating year
Previous editions are obsolete Page 4 form HUD-40110-1)(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 approved
plans.
2. Outcomes Assessed. Assess your program's success in enabling HOPWA beneficiaries to establish and/or better maintain a
stable living environment in housing that is safe, decent, and sanitary, and improve access to care. Compare current year results
to baseline results for clients. Describe how program activities/projects contributed to meeting stated goals. If program did not
achieve expected targets, please describe how your program plans to address challenges in program implementation and the steps
currently being taken to achieve goals in next operating year. If your program exceeded program targets,please describe
strategies the program utilized and how those contributed to program successes.
3. Coordination. Report on program coordination with other mainstream housing and supportive services resources, including
the use of committed leveraging from other public and private sources that helped to address needs for eligible persons identified
in the Consolidated Plan/Strategic Plan.
4. Technical Assistance. Describe any program technical assistance needs and how they would benefit program beneficiaries.
c. Barriers and Trends Overview
Provide a narrative addressing items 1 through 3. Explain how barriers and trends affected your program's ability to achieve the
objectives and outcomes discussed in the previous section.
1. Describe any barriers(including regulatory and non-regulatory)encountered in the administration or implementation of
the HOPWA program, how they affected your program's ability to achieve the objectives and outcomes discussed,and,
actions taken in response to barriers, and recommendations for program improvement. Provide an explanation for each
barrier selected.
❑HOPWA/HUD Regulations ❑Planning ❑ Housing Availability ❑ Rent Determination and Fair Market
Rents
❑ Discrimination/Confidentiality ❑ Multiple Diagnoses ❑Eligibility ❑Technical Assistance or Training
❑Supportive Services ❑Credit History ❑ Rental History El Criminal Justice History
❑ Housing Affordability
❑Geography/Rural Access El Other,please explain further
Previous editions are obsolete Page 5 form 111ID-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 HMAIDS,
Chart 1 B 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. Plannin Estimate of Area's Unmet Needs for HvP::1A-Eli ible Households
1. Total number of households that have unmet
housing subsidy assistance need.
2. From the total reported in Row 1, identify the
number of households with unmet housing needs
by type of housing subsidy assistance:
a.Tenant-Based Rental Assistance (TBRA)
b.Short-Term Rent, Mortgage and Utility payments
(STRMU)
• Assistance with rental costs
• Assistance with mortgage payments
• Assistance with utility costs.
c. Housing Facilities, such as community residences,
SRO dwellings, other housing facilities
Previous editions are obsolete Page 6 form HUD-40110-D(Expiration Date: 10/31/2017)
2. Recommended Data Sources for Assessing Unmet Need (check all sources used)
X =Data as reported in the area Consolidated Plan,e.g.Table I B,CP;•1P 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 waitins lists for assistance or other assessments on need including those
completed by HOPWA competitive grantees operating in the region.
=Data from prisons orjails on persons being discharged with HIV/AIDS,ifmandatory testing is conducted
=Data from local Ryan White Planning Councils or reported in CARE Act Data Reports,e.g.number of clients with permanent
hUllJln�
=Data collected for HIV/AIDS surveillance reporting or other health assessments,e.g.local health department or CDC surveillance data
End of PART 1
Previous editions are obsolete Page 7 form HUD-401 10-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
[21 Amount
of Leveraged [31 Type of 141 Housing Subsidy
111 Source of Leveraging Funds Contribution Assistance or Other Support
Public Funding
❑Housing Subsidy Assistance
Ran White-Housing Assistance ❑Other Support
❑Housing Subsidy Assistance
Ran White-Other ❑Other Support
❑Housing Subsidy Assistance
Housing Choice Voucher Program ❑Other Support
[]Housing Subsidy Assistance
Low Income Housing Tax Credit ❑Other Support
❑Housing Subsidy Assistance
HOME ❑Other Su port
❑Housing Subsidy Assistance
Shelter Plus Care ❑Other Support
El Housing Subsidy Assistance
Emergency Solutions Grant ❑Other Su ort
❑Housing Subsidy Assistance
Other Public: port
❑Housing Subsidy Assistance
Other Public: port
❑Housing Subsidy Assistance
Other Public: ❑Other Support
❑Housing Subsidy Assistance
Other Public: port
❑Housing Subsidy Assistance
Other Public: ❑Other Support
Private Funding
❑Housing Subsidy Assistance
Grants ❑Other Support
❑Housing Subsidy Assistance
In-kind Resources ❑Other Su ort
❑Housing Subsidy Assistance
Other Private: ❑Other Su port
❑Housing Subsidy Assistance
Other Private: El Other Support
Other Funding
❑Housing Subsidy Assistance
Grantee/Project S onsor/Subreci fent(Agency)Cash ❑Other Support
Resident Rent Pa ments by Client to Private Landlord
TOTAL Sum of all Rows
Previous editions are obsolete Page 8 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 f r definition of progrum income. (Additional information on program income is
available in the HOP WA Grantee Oversight Resource Guide).
A. Total Amount Program Income and Resident Rent Payment Collected During the Operating Year
Total Amount of
Program Income
Program Income and Resident Rent Payments Collected (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)
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.
Total Amount of Program
Income Expended
Program Income and Resident Rent Payment Expended on (for this operating year)
HOPWA programs
1. Program Income and Resident Rent Payment Expended on Housing Subsidy Assistance costs
2. Program Income and Resident Rent Payment Expended on Supportive Services and other non-
direct housing costs
3. Total Program Income Expended(Sum of Rows 1 and 2)
End of PART 2
Previous editions are obsolete Page 9 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 housing that were supported
with HOPWA or other federal,state,local,or private funds for the purposes of providing housing assistance and support to
persons living with HIV/AIDS and their families.
Note: The total households assisted with HOP WA 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
111 Output: Households 121 Output:Funding
HOPWA Leveraged
HOPWA Performance Assistance Households HOPWA Funds
Planned Goal a. b. C. d. e. f.
and Actual
vA.
3 a
HOPWA Housing Subsidy Assistance [11 Output Households 121 Outopat:Fundis
I. Tenant-Based Rental Assistance
a. Permanent Housing Facilities:
Received Operating Subsidies/Leased units(Households Served)
b. ransitional/Short-term Facilities:
Received Operating Subsidies/Leased units(Households Served)
(Households Served)
a. Permanent Housing Facilities:
Capital Development Projects placed in service during the operating year
(Households Served)
3b. ransitional/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 Housia Units 2 Ou at:Fundis
8. Facility-based units;
Capital Development Projects not yet opened(Housing Units)
Stewardship Units subject to 3 or 10 year use agreements
10. Total Housing Developed
Sum of Rows 8&9)
Supportive Services
ill Output Households 17.1 outpt-Funding
I la. Supportive Services provided by project sponsors/subrecipient that also delivered
HOPWA housing subsidy assistance
I lb. Supportive Services provided by project sponsors/subrecipient that only provided
.Supportive services.
12. Adjustment for duplication(subtract)
13. Total Supportive Services
(Columns a.—d.equal the sum of Rows 11 a.&b.minus Row 12;Columns e.and
f.equal the sum of Rows IIa.&l lb.
Housing Information Services 111 Output Households 121 Output:Funding
14. Housing Information Services
15. otal Housing Information Services
Previous editions are obsolete Page 10 form HUD-40110-D(Expiration Date:10/31/2017)
Grant Administration and Other Activities I I I Output Households 121 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°'o of portion of HOP"A grant as�arded)
20. otal Grant Administration and Other Activities
(Sum of Rows 16—19)
121 Outputs: HOPWA Funds
Total Expended Expended
Budget Actual
I, 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 I11 Output:Number of Households 121 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
Health/medical/intensive care services,if approved
7. Note: Client records must conform with 24 CFR¢574.310
8. Legal services
9. Life skills management(outside of case management)
10. Meals/nutritional services
11. Mental health services
12. Outreach
13. Transportation
Other Activity(if approved in grant agreement).
14. Specify:
Sub-Total Households receiving Supportive Services
15. Sum of Rows 1-14)
16. Adjustment for Duplication subtract
TOTAL Unduplicated Households receiving
Supportive Services(Column 111 equals Row 15
17. minus Row 16;Column 21 equals sum of Rows 1-14)
Previous editions are obsolete Page 11 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 STRMUin Row a.. column[1]and the total amount of HOPW4 funds reported as
expended in Row a., column[2]equals the household and expenditure total reported for STRaWU in Part 3, Chart 1, Row 4, Columns b. and f.,
respectively.
Data Check: The total number of households reported in Column[]/, Rows b.. c., d., e., and J:equal the total number of STRMUhouseholds
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
STR,llU expenditures reported in Column[21. Row a.
1 I Output: Number of 121 Output: Total
Housing Subsidy Assistance Categories(STRMU) Households Served HOPWA Funds Expended
on STRMU during
Operating Year
Total Short-term mortgage,rent and/or utility(STRMU)
a. assistance
Of the total STRMU reported on Row a,total who received
b• assistance with mortgage costs ONLY.
Of the total STRMU reported on Row a,total who received
C. assistance with mortgage and utility costs.
Of the total STRMU reported on Row a,total who received
d, assistance with rental costs ONLY.
Of the total S'l-RMU reported on Row a,total who received
e. assistance with rental and utility costs.
Of the total S'fRMU reported on Row a.total who received
f assistance with utility costs ONLY.
Direct program deliver} costs(e.g.,program operations staff
time)
9.
End of PART 3
Previous editions are obsolete Page 12 form 1111D-40110-D(Expiration Date: 10/31/2017)
Part 4: Summary of Performance Outcomes
In Column [I], 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 13J(E.rited Households)equals the total reported in Column11 J.
Note:Refer to the housing stabilih codes that appear in Part J: Worksheet-Determining Housing Stabilijv Outcomes.
Section 1. Housing Stability: Assessment of Client Outcomes on Maintaining Housing Stability(Permanent Housing and
Related Facilities)
A.Permanent ousing Subsidy Assistance
III Output: Total [2] Assessment:Number of 131 Assessment:Number of
Number of Households that Continued Households that exited this 141 HOPWA Client
Households Receiving HOPWA Housing HOPWA Program;their Housing Outcomes
Served Subsidy Assistance into the Next Status after Exiting
Operating Year
I Fmergenc}Shelter/Streets Unstable Arrangements
Temporarn Housing Temporarily Stable, it ah Reduced
Risk of Homelessness
3 PriN ate Housing
Tenant-Based
Rental 4 Other HOPWA
Assistance Stable Permanent Housing(PH)
Other Subsidy
6 Institution
7 Jail.Prison
Unstable Arrangements
S Disconnected/Unknown
9 Death Life Event
1 EmergenceShelter/Streets Unstable Arrangements
Temporary Housing Temporarily Stable, with Reduced
Risk of Homelessness
t Private Housing
Permanent
Supportive d Other HOPWA
Stable Permanent Housing(PH)
Housing 5 Other Subsidy
Facilities/Units
6 Institution
7 Jail'Prison
S Disconnected,Unknown Unsvable,Arrangements
9 Death Life Event
B.Transitional Housing Assistance
III Output: Total [2]Assessment: Number of 131 Assessment: Number of
Number of Households that Continued Households that exited this
Households Receiving HOPWA Housing HOPWA Program; their 141 HOPWA Client Outcomes
Served Subsidy Assistance into the Next Housing Status after Exiting
Operating Year
I Emergenc}Shelter Streets Unstable Arrangements
2 Temporary Housing Temporarily Stable with Reduced
Risk of Homelessness
Transitional/ 3 Private Housing
Short-Term
Housing 4 Other HOPWA
Facilities/Units Stable Permanent Housing(PH)
5 Other Subside
6 Institution
7 Jail,'Prison
Unstable Arrangements
8 Disconnected,unknmcn
9 Death Life Event
Previous editions are obsolete Page 13 form HUD-40110-1)(Expiration Date.10/31/2017)
B I:Total number of households receiving transitional/short-term housing
assistance whose tenure exceeded 24 months
Section 2. Prevention of Homelessness: Assessment of Client Outcomes on Reduced Risks of Homelessness
(Short-Term Housing Subsidy Assistance)
Report the total number of households that received STRMU assistance in Column [1].
In Column [2], identify the outcomes of the households reported in Column [1] either at the time that they were known to have
left the STRMU program or through the project sponsor or subrecipient's best assessment for stability at the end of the operating
year.
Information in Column [3] provides a description of housing outcomes;therefore, data is not required.
At the bottom of the chart:
• In Row 1 a.,report those households that received STRMU assistance during the operating year of this report,and the
prior operating year.
• In Row lb.,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
[1Output: Total [2] Assessment of Housing Status [3] HOPWA Client Outcomes
number of
households
Maintain Private Housing without subsidy
(e.g.Assistance provided%ompleted and client is stable,not
likely to seek additional support)
Other Private Housing without subsidy
(e.g.client switched housing units and is nova stable,not likely
to seek additional support) Stable/Permanent Housing(PH)
Other HOPWA Housing Subsidy Assistance
Other Housing Subsidy(PH)
Institution
(e.g.residential and long-term care)
Likely that additional STRMU is needed to maintain current
housing arrangements
Transitional Facilities/Short-term Temporarily Stable, with
(e.g.temporary or transitional arrangement) Reduced Risk of Homelessness
Tem porn ry/Non-Permanen t Housing arrangement
(e.g.gave up lease,and moved in with family or friends but
expects to live there less than 90 days)
Emergency Shelter/street
Jail/Prison Unstable Arrangements
Disconnected
Death Life Event
1 a.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).
1 b.Total number of those households that received STRMU Assistance in the operating year of this report that also received
STRMU assistance in the two prior operating years(e.g.households that received STRMU assistance in three consecutive
operating years).
Previous editions are obsolete Page 14 form HUD-401 10-D(Expiration Date: 10/31/2017)
Section 3.HOPWA Outcomes on Access to Care and Support
la. Total Number of Households
Line [1]: For project sponsors/subrecipients that provided HOPWA housing subsidy assistance during the operating year
identify in the appropriate row the number of households that received HOPWA housing subsidy assistance(TBRA,
STRMU,Facility-Based,PHP and Master Leasing)and HOPWA funded case management services. Use Row c.to adjust
for duplication among the service categories and Row d.to provide an unduplicated household total.
Line[2]: For project sponsors/subrecipients that did NOT provide HOPWA housing subsidy assistance identify in the
appropriate row the number of households that received HOPWA funded case management services.
Note: These numbers will help you to determine which clients to report Access to Care and Support Outcomes for and will be
used by HUD as a basis for analyzing the percentage of households who demonstrated or maintained connections to care and
support as identified in Chart lb. below.
Total Number of Households
1. For Project Sponsors/Subrecipients that provided HOPWA Housing Subsidy Assistance: Identify the total number of households that
received the following HOPWA-funded services:
a. Housing Subsidy Assistance(duplicated)-TBRA,STRMU,PHP,Facility-Based Housing,and Master Leasing
b. Case Management
C. Adjustment for duplication(subtraction)
d. Total Households Served by Project Sponsors/Subrecipients with Housing Subsidy Assistance(Sum of Rows a.b.
minus Row c.
2. For Project Sponsors/Subrecipients did NOT provide HOPWA Housing Subsidy Assistance: Identify the total number of households that
received the following HOPWA-funded service:
a. HOPWA Case Management
b. Total Households Served by Project Sponsors/Subrecipients without Housing Subsidy Assistance
lb. Status of Households Accessing Care and Support
Column[1]: Of the households identified as receiving services from project sponsors/subrecipients that provided HOPWA
housing subsidy assistance as identified in Chart Ia.,Row 1 d.above,report the number of households that demonstrated
access or maintained connections to care and support within the program year.
Column[2]: Of the households identified as receiving services from project sponsors/subrecipients that did NOT provide
HOPWA housing subsidy assistance as reported in Chart Ia.,Row 2b.,report the number of households that demonstrated
improved access or maintained connections to care and support within the program year.
Note:For information on types and sources of income and medical insurance/assistance, refer to Charts below.
[I] For project [21 For project
sponsors/subrecipients that sponsors/subrecipients that
Categories of Services Accessed provided HOPWA housing subsidy did NOT provide HOPWA Outcome
assistance,identify the households housing subsidy assistance, Indicator
who demonstrated the followingidentify the households who
' demonstrated the following:
1.Has a housing plan for maintaining or establishing stable on- Supportfor
going housing
Housing
2.Had contact with case manager/benefits counselor consistent
with the schedule specified in client's individual service plan Access to
(may include leveraged services such as Ryan White Medical Support
Case Management)
3.Had contact with a primary health care provider consistent Access to
with the schedule specified in client's individual service plan Health Care
4.Accessed and maintained medical insurance/assistance Access
Health Care
5.Successfully accessed or maintained qualification for sources Sources of
of income Income
Previous editions are obsolete Page 15 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 • Veterans Affairs Medical Services
use local program • AIDS Drug Assistance Program(ADAP) Ryan White-funded Medical or Dental
name • State Children's Health Insurance Program Assistance
• MEDICARE I lealth Insurance Program,or (SCHIP),or use local program name
use local program name
Chart 1b.,Row 5: Sources of Income include, but are not limited to the following Reference only)
• Famed Income • Child Support General Assistance(GA),or use local
• Veteran's Pension Social Security Disability Income(SSDI) program name
• Unemployment Insurance Alimony or other Spousal Support Private Disability Insurance
• Pension from Former Job Veteran's Disability Payment • Temporary Assistance for Needy
• Supplemental Security Income(SSI) • Retirement Income from Social Security Families(TANF)
• Workers Compensation Other Income Sources
lc. Households that Obtained Employment
Column [I]: Of the households identified as receiving services from project sponsors/subrecipients that provided HOPWA
housing subsidy assistance as identified in Chart I a., Row I d. 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 1 a., Row 2b.,report on the number of households that include
persons who obtained an income-producing job during the operating year that resulted from HOPWA-funded Job training,
employment assistance, education or case management/counseling services.
Note: This includes jobs created by this project sponsorlsubrecipients or obtained outside this agency.
Note: Do not include jobs that resulted from leveraged job training, employment assistance, education or case
management/counseling services.
I For project sponsors/subrecipients that (21 For project sponsors/subrecipients that did
Categories of Services Accessed provided HOPWA housing subsidy NOT provide HOPWA housing subsidy assistance,
assistance,identify the households who identify the households who demonstrated the
demonstrated the following: following:
Total number of households that
obtained an income- roducin 'ob
End of PART 4
Previous editions are obsolete Page 16 form HUD-40110-11)(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 iso tp ional.
Permanent Stable Housing Temporary Housing Unstable Life Event
Housing Subsidy (#of households (2) Arrangements (9)
Assistance remaining in program (1+7+8)
plus 3+4+5+6)
Tenant-Based
Rental Assistance
(TBRA)
Permanent Facility-
based Housing
Assistance/Units
Transitional/Short-
Term Facility-based
Housing
Assistance/Units
Total Permanent
HOPWA Housing
Subsidy Assistance
Reduced Risk of Stable/Permanent Temporarily Stable,with Reduced Risk of Unstable Life Events
Homelessness: Housing Homelessness Arrangements
Short-Term
Assistance
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 facilitv).
Temporary Housing
2 =Temporary housing-moved in with family/friends or other short-term arrangement, such as Ryan White subsidy,transitional
housing for homeless, or temporary placement in institution (e.g., hospital,psychiatric hospital or other psychiatric facility,
substance abuse treatment facility or detox center).
Unstable Arrangements
I =Emergency shelter or no housing destination such as places not meant for habitation (e.g., a vehicle, an abandoned building,
bus/train/subway station, or anywhere outside).
7=Jail/prison.
8= Disconnected or disappeared from project support, unknown destination or no assessments of housing needs were
undertaken.
Life Event
9= Death, i.e., remained in housing until death. This characteristic is not factored into the housing stability equation.
Tenant-based Rental Assistance: Stable Housing is the sum of the number of households that(i)remain in the housing and(ii)
those that left the assistance as reported under: 3,4, 5, and 6. Temporary Housing is the number of households that accessed
assistance, and left their current housing for a non-permanent housing arrangement, as reported under item: 2. Unstable
Situations is the sum of numbers reported under items: 1, 7,and 8.
Previous editions are obsolete Page 17 form HUD-40110-1)(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, and 6. Other Temporary Housing, is the
number of households that accessed assistance, and left their current housing for a non-permanent housing arrangement, as
reported under item 2. Unstable Situations is the sum of numbers reported under items: 1, 7, and 8.
Tenure Assessment. A baseline of households in transitional/short-term facilities for assessment purposes, indicate the number
of households whose tenure exceeded 24 months.
STRMU Assistance: Stable Housing is the sum of the number of households that accessed assistance for some portion of the
permitted 21-week period and there is reasonable expectation that additional support is not needed in order to maintain
permanent housing living situation (as this is a time-limited form of housing support)as reported under housing status: Maintain
Private Housing with subsidy; Other Private with Subsidy; Other HOPWA support; Other Housing Subsidy; and Institution.
Temporarily Stable, with Reduced Risk of Homelessness is the sum of the number of households that accessed assistance for
some portion of the permitted 21-week period or left their current housing arrangement for a transitional facility or other
temporary/non-permanent housing arrangement and there is reasonable expectation additional support will be needed to maintain
housing arrangements in the next year, as reported under housing status: Likely to maintain current housing arrangements, with
additional STRMU assistance; Transitional Facilities/Short-term; and Temporary/Non-Permanent Housing arrangements
Unstable Situation is the sum of number of households reported under housing status: Emergency Shelter;Jail/Prison;and
Disconnected.
End of PART 5
Previous editions are obsolete Page 18 form HUD-40110-1)(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
Operating Year for this report
HUD Grant Number(s) From(nun dd y),) To(mm ddyy) ❑ Final Yr
❑ Yr L ❑ 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 Amount of Non-HOPNVA Funds Expended in Support of the
Developed with HOPWA Stewardship Units during the Operating Year
funds
Total Stewardship Units
(subject to 3-or 10-year useperiods)
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? ❑ 5es,protect information:do not list
❑ Not confidential:information can be made available to the public
If the site is not confidential:
Please provide the contact information,phone,
email address/location,if business address is
different from facility address
I certify that the facility that received assistance for acquisition. rehabilitation,or new construction from the Housing Opportunities
for Persons with AIDS Program has operated as a facility to assist HOPWA-cligible 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.
1 hereby cert[` that all the information stated herein,as well as ant,information provided in the accompaniment herewith. is true and accurate.
Name&Title of Authorized Official of the organization that continues Signature&Date(mm/dd/yy)
to operate the facility:
Name&Title of Contact at Grantee Agency Contact Phone(with area code)
(person who can answer questions about the report and program)
End of PART 6
Previous editions are obsolete Page 19 form HUD-40110-1)(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 NOP WA 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 Rom, 18 equals the total number of individuals served through
housing subsidy assistance reported in Chart a. above.
Total HOPWA
Category Eligible Individuals
Receiving Housing
Subsidy Assistance
1. 1 Continuing to receive HOPWA support from the prior operating year
New Individuals who received HOPWA Housing Subsidy Assistance support during Operating Year
Place not meant for human habitation
2. (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 orjuvenile 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 20 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 I lomeless(See Definition section of CAPER). The totals in Chart c. do not need to
equal the total in Chart b., Row 5.
Number of Number of Chronically
Category Homeless Homeless
Veteran(s)
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 Trans eg nder.
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 cis determined in Chart a., Row-1 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 lIIV/AIDS who qualified the household to receive HOPWA housing subsidy
assistance(equals the number of IiOPWA 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 21 form ITUD-40110-1)(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.
TOTAL(Sum of
Male Female Trans ender N1 to F Trans ender F to**I Columns A-D)
I. Under 18
2. 18 to 30 years
3. 31 to 50 years
51 years and
4. Older
Subtotal(Sum
5. of Rows 1-4
All Other Beneficiaries Chart a,Rows 2 and 3
A. B. C. D. E.
TOTAL(Sum of
•Isle Female Trans ender NI to F Trans ender F to N1 Columns A-D)
6. Under 18
7. 18 to 30 years
8. 3 l to 50 years
51 years and
9. Older
Subtotal(Sum
10. of Rows 6-9)
Total Beneficiaries Chart a,Row 4
TOTAL(Sum
11. of Rows 5&10)
Previous editions are obsolete Page 22 form HUD-401 10-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.
HOPWA Eligible Individuals All Other Beneficiaries
[A] Race [C] Race
Category [all individuals [B]Ethnicity [total of [D]Ethnicity
reported in [Also identified as individuals [Also identified as
Section 2,Chart Hispanic or reported in Hispanic or
a.,Row 11 Latino] Section 2,Chart Latino]
a.,Rows 2&31
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 HOP PVA 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 HOP WA housing subsidy assistance should equal Part 3C, Row 7,
Column b and Part 7A, Section 1, Chart a. (Total HOP WA Eligible Individuals Served with HOP WA Housing Subsidy
Assistance).
Note: Refer to http://www.huduser.orQ/portal/datasetslilli12010/select Ceographf, m i.odn for information on area median
income in your community.
Percentage of Area Median Income Households Served with HOPWA Housing Subsidy
Assistance
L 0-30%of area median income(extremely low)
2. 31-50%of area median income(very low)
3. 51-80%of area median income(low)
4. Total(Sum of Rows 1-3)
Previous editions are obsolete Page 23 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 S onsor/Subreci fent 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 tY e o Facili write "Scattered Sites."
HOPWA Name of Facility:
Type of Funds Non-HOPWA funds
Development Expended
this operating this operating Expended
(f applicable)
year year
(if applicable)
❑New construction $ $ Type of Facility [Check only one box.]
El Rehabilitation $ $ ❑ Permanent housing
❑ Short-term Shelter or Transitional housing
[I Acquisition $ $ [1Supportive services only facility
❑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=
❑Yes EJNo
f. Is a waiting list maintained for the facility. 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 24 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 Number
for the Chronically Designated to Number Energy- Number 504 Accessible
Homeless Assist the Star Compliant
Homeless
Rental units constructed
(new)and/or acquired
with or without rehab
Rental units rehabbed
Homeownership units
constructed(if approved)
3. Units Assisted in Types of Housing Facility/Units Leased by Project Sponsor or Subrecipient
Charts 3a., 3b. and 4 are required for each facility. In Charts 3a. and 3b., indicate the type and number of housing units in the
facility, including master leased units,project-based or other scattered site units leased by the organization, categorized by the
number of bedrooms per unit.
Note: The number units may not equal the total number of households sen•ed.
Please complete separate charts for each housing facility assisted. Scattered site units may be grouped together.
3a. Check one only
❑ Permanent Supportive Housing Facility/Units
❑ Short-term Shelter or Transitional Supportive Housing Facility/Units
3b. Type of Facility
Complete the following Chart for all facilities leased, master leased, project-based, or operated with HOPWA funds during the
reporting year.
Name of Project Sponsor/Agency Operating the Facility/Leased Units:
Total Number of Units in use during the Operating Year
Type of housing facility operated by the Cate orized by the Number of Bedrooms per Units
project sponsor/subrecipient SRO/Studio/0 I bdrm 2 bdrm 3 bdrm 4 bdrm 5+bdrm
bdrm
a. Single room occupancy d«wlling
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 Output: Total HOPWA Funds Expended during
Households Operating Year by Project S onsor/subreci lent
a Leasing Costs
b Operating Costs
C. Project-Based Rental Assistance(PBRA)or other leased units
d Other Activity(if approved in grant agreement)Specifv:
e Adjustment to eliminate duplication(subtract)
TOTAL Facility-Based(lousing Assistance
f• Sum Rows a.through d.minus Rory c.)
Previous editions are obsolete Page 25 form HIID-40110-D(Expiration Date: 10/31/2017)
M&C Review Page 1 of 2
Official site of the City of Fort Worth,Texas
CITY COUNCIL AGENDA 1'OR�ORTII
COUNCIL ACTION: Approved on 4/12/2016
`------- REFERENCE„-- `—LOG-- — 19NS ------ — --
DATE: 4/12/2016 NO : C-27671 NAME: ADD ITIONALFUNDINGAIDSO UTREACHCENTER2015-
16
CODE: C TYPE: CONSENT PUBLIC NO
HEARING:
SUBJECT: Authorize Change in Use and Expenditure of Additional Housing Opportunities for Persons with AIDS
Grant Funds in the Amount of$72,000.00 to AIDS Outreach Center, Inc., for a Total Contract Amount
of$624,027.00, Amendment of City Secretary Contract No. 47281 and a Substantial Amendment to
the City's 2014-15 Action Plan (ALL COUNCIL DISTRICTS)
RECOMMENDATION:
It is recommended that the City Council:
1. Authorize a Substantial Amendment to the City's 2014-15 Action Plan;
2. Authorize a change in use and expenditure of additional unprogrammed Housing Opportunities for
Persons with AIDS grant funds in the amount of$72,000.00 to AIDS Outreach Center, Inc.; and,
3. Authorize the City Manager or his designee to execute a contract amendment to City Secretary
Contract No. 47281 with AIDS Outreach Center, Inc., to increase the amount by $72,000.00 for a
total contract amount of$624,027.00.
DISCUSSION:
On August 4, 2015, the City Council approved the 2015-16 Action Plan, including the execution of a
contract with AIDS Outreach Center, Inc. (AOC)for Housing Opportunities for Persons with AIDS
(HOPWA) grant funds from the United States Department of Housing and Urban Development(HUD)
in the amount of$552,027.00 (M&C G-18521, City Secretary Contract No. 47281). AOC utilizes the
HOPWA funds for financial assistance programs including Short Term Rent, Mortgage and Utility
Assistance (STRMU)to HOPWA-eligible clients. Due to client demand, AOC has spent all HOPWA
funds allocated for STRMU in its 2015-16 contract.
AOC has requested additional HOPWA funds in order to ensure continued levels of service to eligible
clients and to assist the City in meeting its Consolidated Plan goals. The Action Plan included the
authority to amend the various 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
regulations regarding the use of Federal grant funds. Staff has identified available HOPWA funds left
over from the 2014-15 allocation and recommends an amendment to the current contract with AOC to
increase the amount by $72,000.00, for a total contract amount of$624,027.00. The additional
$72,000.00 will pay for STRMU services to HOPWA-eligible clients.
Staff recommends the change in use and expenditure of$72,000.00 of additional unprogrammed
HOPWA funds to AOC. Federal regulations do not require a public comment period for this change
in use of HOPWA funds.
Services by AOC are available in ALL COUNCIL DISTRICTS.
FISCAL INFORMATION/CERTIFICATION:
The Director of Finance certifies that Fiscal Year 2015 included appropriations in the amount of
$72,000.00 in the Grants Fund for Housing Opportunities for Persons with AIDS programs. As of
March 24, 2016, the appropriations have not been expended. Upon approval of these
recommendations, the Director of Finance certifies that funds are available within the existing
http://apps.cfwnet.org/councilpacket/mc_review.asp?ID=22162&councildate=4/12/2016 6/10/2016
M&C Review Page 2 of 2
appropriations and can be reallocated to City Secretary Contract No. 47281 with AIDS Outreach
Center, Inc.
TO
Fund Department Account Project Program Activity Budget Reference# Amount
ID I ID Year (Chartfield 2)
21001 1 0190463 1 5330201 000263 991981 2015 $72,000.0
FROM
Fund Department Account Project Program Activity Budget Reference# Amount
ID ID Year (Chartfield 2)
21001 0190463 5330201 000263 991981 2015 $22,481.8
21001 0190463 5330201 000263 991982 2015 $1,782.2
21001 0190463 5330201 000263 991983 2015 $8,994.0
21001 0190463 5330201 000263 991980 2015 $1,217.7
21001 0190463 5330201 000263 991984 2015 $5,155.51
21001 1 0190463 5330201 000263 991985 2015 $32,368.6
Submitted for City Manager's Office by: Fernando Costa (6122)
Originating Department Head: Aubrey Thagard (8187)
Additional Information Contact: Bette Chapman (6125)
ATTACHMENTS
Form 1295 AOC.pdf
http://apps.cfwnet.org/council_packet/mc review.asp?ID=22162&councildate=4/12/2016 6/10/2016