HomeMy WebLinkAboutContract 60304CSC No. 60304
STATE OF TEXAS §
COUNTY OF TARRANT §
This contract ("Contract") is made and entered into by and between the City of Fort Worth
(hereafter "City") and Tarrant County Samaritan Housing, INC. (hereafter "Agency"), a Texas non-
profit corporation. City and Agency may be referred to individually as a "Party" and jointly as "the
Parties".
The Parties state as follows:
WHEREAS, City receives grant monies from the United States Department of Housing and
Urban Development through the Housing Opportunities for Persons with AIDS Program
("HOPWA") Program, Program No. TX-H-23-17002, Catalog of Federal Domestic Assistance No.
14.241;
WHEREAS, the HOPWA program is intended to address the needs of eligible persons
associated with the challenge of living with HIV/AIDS and their families;
WHEREAS, Agency submitted a proposal to use HOPWA funds for an eligible program
under the HOPWA Regulations whereby Agency will provide services to low and moderate income
persons;
WHEREAS, City citizens, the Community Development Council, and the City Council have
determined that HOPWA programs are needed by the City's citizens.
NOW, THEREFORE, the Parties understand and agree as follows:
1. INCORPORATION OF RECITALS
City and Agency hereby agree that the recitals set forth above are true and correct and form
the basis upon which the Parties have entered into this Contract.
2. DEFINITIONS
In addition to terms defined in the body of this Contract, the terms set forth below shall
have the definitions ascribed to them as follows:
Area Median Income or AMI means the median family income for the Fort Worth -Arlington
metropolitan statistical area as established annually by HUD. The 2022 income limits are attached
hereto as EXHIBIT "A-1" — 2023 HUD Income Limits.
Business Diversity Enterprise Ordinance or BDE means the City's Business Diversity Ordinance,
Ordinance No. 24534-11-2020, as may be amended from time to time.
Complete Documentation means the following documentation as applicable:
HOPWA PSA CONTRACT 2023-2024
Tarrant County Samaritan Housing, INC
Rev. 10-3-2023
Page 1
OFFICIAL RECORD
CITY SECRETARY
FT. WORTH, TX
Attachments I, II, and III, with supporting documentation including:
o Proof of expense: copies of timesheets, invoices, leases, service contracts or
other documentation showing that payment is due by Agency.
o Proof of payment: cancelled checks, bank statements, or wire transfers
necessary to demonstrate that amounts due by Agency were actually paid by
Agency.
o Proof of client eligibility: Source Documentation sufficient to show that
clients participating in the Program are HOPWA Eligible Clients as described
in Section 6.
Complete Documentation shall meet the standards described in the attached
EXHIBIT "F"- Standards for Complete Documentation.
• Any other document or record reasonably necessary to verify costs spent and client
eligibility for the Program.
DBE means disadvantaged business enterprise in accordance with 49 CFR Part 26.
Director means the Director of the City's Neighborhood Services Department.
Effective Date means October 1, 2023.
HOPWA means Housing Opportunities for Persons with AIDS.
HOPWA Eligible Client means a client whose annual income adjusted for family size does not
exceed 80% of AMI using the most current HUD Income Guidelines and Technical Guidance for
Determining Income and Allowances verified by Source Documentation. The client must also have
a documented diagnosis of HIV/AIDS.
HOPWA Funds means the HOPWA grant funds supplied by City to Agency under the terms of
this Contract.
HOPWA Regulations means regulations found at 24 CFR Part 574 et seq.
HUD means the United States Department of Housing and Urban Development.
IDIS means Integrated Disbursement Information System, HUD's project tracking system.
Neighborhood Services Department means the City's Neighborhood Services Department.
Neighborly Software — Online database maintained by the City of Fort Worth through which
Agency is required to submit monthly reimbursement requests.
OMB means the Office of Management and Budget.
Program means the services described in EXHIBIT "A" — Program Summary.
HOPWA PSA CONTRACT 2023-2024 Page 2
Tarrant County Samaritan Housing, INC
Rev. 10-3-2023
Reimbursement Request means all reports and other documentation described in Section 9.
Source Documentation means documentation of full household income of any type described under
the definition of annual income in 24 CFR Part 5.609, including but not limited to copies of
paychecks, Social Security and disability verification letters, interest or rental income statements,
retirement income statements, child support and alimony verification, unemployment benefit letters,
and the like.
Unduplicated Clients means a count of HOPWA Eligible Clients served at least once in the
Contract Term. HOPWA Eligible Clients served more than once in the Contract Term will only be
counted the first time they are served when determining the total count of Unduplicated Clients.
3. TERM.
The term of this Contract (Contract Term) begins on the Effective Date and terminates on
September 30, 2024 unless earlier terminated as provided in this Contract. This Contract may be
extended, by the written mutual agreement of the Parties, if such extension is necessary for
completion of the program, or to amend the contracts if necessary to achieve program goals provided
any amendment is within the scope of the program and in compliance with City policies and all
applicable laws and regulations governing the use of federal grant funds. The Contract Term shall
include any extension, if exercised, as provided herein.
4. DUTIES AND RESPONSIBILITIES OF CITY.
OP 4.1 Provide H WA Funds.
City shall provide up to $1,300,000.00 of HOPWA Funds under the terms and conditions of
this Contract.
4.2 Monitor.
City will monitor the activities and performance of Agency and any of its contractors,
subcontractors or vendors as necessary, but no less than annually. Monitoring by City will include
determining whether Agency is meeting the requirements of the HOPWA Regulations during the
term of this Contract.
5. DUTIES AND RESPONSIBILITIES OF AGENCY.
5.1 Required Services.
Agency shall perform the services described in EXHIBIT "A" — Program Summary in
accordance with the terms and conditions of this Contract.
5.2 Use of HOPWA Funds.
5.2.1. Compliance with HOPWA Regulations and Contract.
Agency shall be reimbursed for eligible Program costs with HOPWA Funds only if City
HOPWA PSA CONTRACT 2023-2024 Page 3
Tarrant County Samaritan Housing, INC
Rev. 10-3-2023
determines in its sole discretion that:
5.2.1.1 Costs are eligible expenditures in accordance with HOPWA Regulations.
5.2.1.2 Costs are in compliance with this Contract and are reasonable and consistent
with industry norms.
5.2.1.3 Complete Documentation, as applicable, is submitted to City by Agency.
5.2.2 Budget
5.2.2.1 The HOPWA Funds will be paid on a reimbursement basis in accordance
with EXHIBIT `B" - Budget.
5.2.2.2 During the term of this Contract, Agency may submit written requests to
increase or decrease line -item amounts in the Budget, including an
explanation of why such increases or decreases are necessary. All
requests shall be approved by Director in writing, with such approval
being in the Director's sole discretion. If Director approves the Agency's
proposed Budget amendment (as approved, the "Amended Budget"),
then the Amended Budget will take effect on the first day of the month
following the month in which it was approved by Director, unless
otherwise specified in the amendment. All requests for Budget
amendments must be submitted by April 5, 2024.
5.2.3 Change in Program Budget.
5.2.3.1 Agency will notify City promptly of any additional funds it receives for
operation of the Program, and City reserves the right to amend this
Contract in such instances to ensure compliance with HUD regulations
governing cost allocation.
5.2.3.2 Agency agrees to utilize the HOPWA Funds to supplement rather than
supplant funds otherwise available for the Program.
5.2.4 Pavment of HOPWA Funds to Agency.
HOPWA Funds will be disbursed to Agency upon City's approval of Reimbursement
Requests including submission of Complete Documentation to City in compliance with Section 9.
If Agency expends all funds budgeted for the Program prior to September 30, 2024, City may hold
back a small amount of the HOPWA Funds until the end of the term. During this interim period,
Agency must continue to submit Attachment III — Client Data Report in EXHIBIT "D" —
Reimbursement Forms monthly. It is expressly agreed by the Parties that any HOPWA Funds not
spent or not approved for reimbursement to Agency shall remain with City.
5.3 Program Performance Milestones.
5.3.1 Agency represents that the Program will achieve the following milestones in
HOPWA PSA CONTRACT 2023-2024 Page 4
Tarrant County Samaritan Housing, INC
Rev. 10-3-2023
accordance with EXHIBIT "A" — Program Summary and the table below:
I" 11prl-
Month Expenditures
3 25%
6
50%
9
75%
12
100%
Unduplicated Clients as
specified in EXHIBIT
"A" — Program
Summary
25%
50%
75%
100%
5.3.2 Failure of Agency to meet these milestones or a material deviation from them as
outlined in this Section 5.3 is a breach of this Contract. For the purpose of this Section, "material
deviation" shall mean more than 10% lower than the specified goal. In the event of such breach,
City reserves the right in its sole option to delay or withhold payment of Reimbursement Requests,
to lower Agency's allocation of HOPWA Funds, or to terminate this Contract.
5.3.2.1 Policy.
To ensure the Program meets the client goals provided by Agency and included herein, City
will periodically review Program performance to ensure the expenditure of the funds is roughly
proportional to the number of eligible, unduplicated clients being served, as described above in 5.3.1.
City expects that most programs will expend funds in a proportional amount to clients served, but
City reserves the ability to take into account unique program characteristics that may impact the ratio
between expenditures and clients served.
5.3.2.2 Review.
At the end of each quarter, City will review the information provided to City by Agency.
City will review the amount of funds expended compared to the percentage of eligible, unduplicated
clients served. If City believes in its sole discretion that Agency is (i) in danger of not spending the
full amount of the funds allocated, (ii) in danger of expending all funds prior to serving 100% of the
unduplicated client goal (meaning the percentage of funds expended relative to the overall funding
allocated is not within 10% of the percentage of eligible, unduplicated clients served relative to the
overall client goal), or is (iii) in danger of not otherwise meeting the performance goals within this
Contract, City will notify Agency and set up a Program Review Meeting ("Review Meeting").
Failure by Agency to attend the Review Meeting is considered a breach of this contract and City
may invoke any and all remedies included herein. During the Review Meeting, City and Agency
will review the information provided, the Program, and discuss any concerns. If the City believes
that no additional action is needed to ensure Agency's performance, no additional requirements will
be put in place; however, if the City, in its sole discretion, believes that additional requirements are
needed to ensure Agency's performance, City may require the Agency to enter into a Corrective
Action Plan ("CAP") or may move forward with deobligating funds from the Contract.
5.3.2.3 Corrective Action Plans.
A CAP will be unique to the Agency and the Program and will be designed to ensure that the
Agency (i) expends the funds allocated to it by the City, and (ii) serves the required number of
HOPWA PSA CONTRACT 2023-2024 Page 5
Tarrant County Samaritan Housing, INC
Rev. 10-3-2023
unduplicated clients through the Program. A CAP may require additional outreach or marketing,
additional reporting, additional monitoring, or any other mechanism that will reasonably ensure the
Program goals are met and that expenditures are roughly proportional to the number of eligible,
unduplicated clients served.
5.3.2.4 Deobligation of Funds
If after any quarterly review the City determines that a CAP will not be sufficient to ensure
that the Agency (i) expends the funds allocated to it by the City, and (ii) serves the required number
of unduplicated clients through the Program, City shall be able to deobligate a portion of the funds
provided to Agency that is at -risk of not being expended or that is the proportional amount of funds
compared to the number of eligible, unduplicated clients that are anticipated to not be served. Any
deobligation shall be in the form of a contract amendment. By way of example, if an agency was
allocated $100,000 and was required to serve 100 unduplicated clients, if that agency was expected
to only be able to serve 75% of its client goal, then City would allow agency to keep 75% of the
allocated funding and deobligate 25% of the funds to correspond with the 25% of clients that are
anticipated to not be served.
5.3.3 Failure to comply with the Corrective Action Plan (CAP), meet the Program Goals,
or otherwise comply with 114 Unduplicated Clients may, in City's sole discretion, disqualify
Agency for consideration under the City's Request for Proposals for the 2024-2025 Program Year
for federal grant funds.
5.3.4 Amendments to performance milestones regarding HOPWA funds must be approved
by the Director in writing, with such approval being in the Director's sole discretion. If Director
approves the Agency's proposed amended performance milestones (as approved, the "Amended
Performance Milestones"), then the Amended Performance Milestones shall be memorialized in
a written amendment to this Contract. The Amended Performance Milestones will take effect on the
first day of the month following the month in which the Contract Amendment is executed unless
otherwise specified in the amendment. Notwithstanding the above, any amendments to this Contract
shall not reduce the number of Unduplicated Clients stated in Section 5.3.3 and in EXHIBIT "A" -
Program Summary.
5.4 Identifv Program Expenses Paid with HOPWA Funds.
Agency will keep accounts and records in such a manner that City may readily identify and
account for Program expenses reimbursed with HOPWA Funds. These records shall be made
available to City for audit purposes and shall be retained as required hereunder.
5.5 Program Subcontracts.
Agency shall not enter into a subcontract with another agency, contractor, or vendor to
provide a service to clients for any part of the Program that will be paid with HOPWA Funds without
City's written consent.
6. CLIENT ELIGIBILITY VERIFICATION.
6.1 Client Eligibility.
Agency will document the eligibility of all prospective clients. Agency may redact the
HOPWA PSA CONTRACT 2023-2024 Page 6
Tarrant County Samaritan Housing, INC
Rev. 10-3-2023
client's personal information and substitute a client number. Agency will document client eligibility
as follows:
6.1.1 Income.
Agency must verify all new clients' income eligibility with Source Documentation. Agency
must use the annual income definition used by 24 CFR Part 5.609 to establish client income
eligibility and must use the most current HUD Income Guidelines.
6.1.2 Diagnosis.
Agency must submit a signed, dated statement that the client's file contains documentation
of the client's diagnosis of HIV/AIDS. The HIV/AIDS diagnosis must be made by a licensed health
care provider; a client's self -certification of diagnosis is not sufficient. Agency should not submit
the actual diagnosis to City.
6.1.3 Emergencv Need.
For clients receiving short term rental, mortgage or utility assistance, Agency must also
verify and document that the client has an emergency need, such as sudden loss of income, eviction,
utility shutoff, or extraordinary and unexpected healthcare costs. Agency must submit its policy
regarding documenting emergency need to City by October 1, 2023.
6.2 Submission of Complete Documentation.
Agency must submit copies of documentation of client eligibility described in Section 6.1
with Attachment III in each month's Reimbursement Request for all Unduplicated Clients.
6.3 Maintain Documentation.
Agency must maintain copies of all documentation required by this Section 6 for 5 years
following the expiration of the Contract term. This Section shall survive the earlier terminations or
expirations of this Contract.
7. ADDITIONAL HOPWA REQUIREMENTS.
Agency agrees to comply with all requirements of the HOPWA Program as stated in the
HOPWA Regulations, including but not limited to the following:
7.1 Environmental Review.
HOPWA Funds will not be paid, and costs cannot be incurred until City has conducted an
environmental review and completed an Environmental Review Record as required by 24 CFR Part
58. The environmental review may result in a decision to proceed with, modify, or cancel the
funding for the Program. Further, Agency will not undertake or commit any funds to physical or
choice limiting actions as described in any applicable federal regulations. Any violation of this
provision will (i) cause this Contract to terminate immediately; and (ii) require Agency to repay City
the HOPWA Funds it has already received and forfeit any future payments of HOPWA Funds.
7.2 Contract Not Constituting Commitment of Funds.
Notwithstanding any provision of this Contract, the Parties agree and acknowledge that this
Contract does not constitute a commitment of funds, and that such commitment of funds or approval
HOPWA PSA CONTRACT 2023-2024 Page 7
Tarrant County Samaritan Housing, INC
Rev. 10-3-2023
may occur only upon (i) satisfactory completion of an environmental review and receipt by City of
an authorization to use grant funds from HUD under 24 CFR Part 58, (ii) approval of City's 2023 -
2024 Action Plan, and (iii) receipt by City of grant agreement from HUD.
7.3 Monitoring.
7.3.1 Agency understands and agrees that it will be subject to monitoring by City for
compliance with terms and provisions of this Contract and the HOPWA Regulations for the term
of this Contract. Agency is subject to such monitoring during the term of this Contract and for 5
years after the Contract term ends. For purposes of this Contract, unless this Contract is earlier
terminated, this 5-year period for monitoring is deemed to begin on October 1, 2024, or October 1,
2025 if the Contract is extended, and shall end no later than September 30, 2030. Agency will
provide reports and access to Program files as requested by City during this 5-year period.
7.3.2 Representatives of City, HUD, HUD Office of Inspector General, and the United
States Comptroller General shall have access during regular business hours, upon 48 hours prior
notice, to Agency's offices and records pertaining to the use of the HOPWA Funds, and to Agency's
officers, directors, agents, employees, contractors, subcontractors and vendors for the purpose of
such monitoring.
7.3.3 In addition to other provisions of this Contract regarding frequency of monitoring,
City reserves the right to perform desk reviews or on -site monitoring of Agency's compliance with
the terms and conditions of this Contract. City shall provide Agency with a written report of the
monitor's findings after each monitoring visit. If the monitoring report notes deficiencies in
Agency's performance, the report shall include requirements for the timely correction of said
deficiencies by Agency. Failure by Agency to take the action specified in the monitoring report may
be cause for suspension or termination of this Contract as provided herein.
7.3.4 Subsections 7.3.1 through 7.3.3 shall be applicable for the Contract term and for 5
years thereafter and shall survive the earlier termination or expiration of this Contract.
7.3.5 Agency shall provide City annually the results of any state or federal monitoring.
Such results shall be submitted within 60 days of receipt of such state or federal monitoring report,
or with the January Reimbursement Request, whichever is earlier.
7.4 Agency Procurement Standards.
Agency shall comply with all applicable federal, state and local laws, regulations, and
ordinances for making procurements under this Contract. In addition to the conflict of interest
provision in Section 14.13.3, Agency shall establish written procurement procedures to ensure that
materials and services are obtained in a cost-effective manner and that provides for full and open
competition. When procuring materials and services for this Contract, Agency shall comply at a
minimum with the procurement standards in 2 CFR Part 200.317 through 2 CFR Part 200.326.
7.4.1 Contracts in excess of $10,000.00 made by Agency using HOPWA Funds must
address termination for cause and convenience including the manner by which such termination shall
be effected and the basis for settlement of the terminated contract, if any, as required by Appendix
HOPWA PSA CONTRACT 2023-2024 Page 8
Tarrant County Samaritan Housing, INC
Rev. 10-3-2023
II (B), 2 CFR Part 200.
7.4.2 Agency shall not make any contract with parties listed on the government wide
System for Award Management, www.sam.gov ("SAM"). Agency must confirm by search of
SAM that all contractors paid with HOPWA Funds are not listed by SAM as being debarred, both
prior to hiring and prior to submitting a Reimbursement Request which includes invoices from any
such contractor. Failure to submit such proofs of search shall be an event of default.
7.5 Cost Principles/Cost Reasonableness.
Agency shall administer its use of HOPWA Funds in compliance with 2 CFR Part 200, as
applicable. The eligibility of costs incurred for performance rendered shall be determined in
accordance with 2 CFR Part 200.400 through 2 CFR Part 200.475.
7.6 Financial Management Standards.
Agency agrees to comply with 2 CFR Part 200, as applicable. Agency also agrees to adhere
to the accounting principles and procedures required therein, utilize adequate internal controls, and
maintain necessary supporting and back-up documentation for all costs incurred in accordance with
2 CFR Part 200.302 and Part 200.303.
7.7 Uniform Administrative Requirements, Cost Principles, and Audit
Requirements.
Agency will comply with the Uniform Administrative Requirements, Cost Principles, and
Audit Requirements for Federal Awards in 2 CFR Part 200, as applicable, or any reasonably
equivalent procedures and requirements that City may require.
7.8 Terms Applicable to Contractors, Subcontractors and Vendors.
Agency understands and agrees that all terms of this Contract, whether regulatory or
otherwise, shall apply to any and all contractors, subcontractors and vendors of Agency which are
in any way paid with HOPWA Funds or who perform any work in connection with the Program.
Agency shall cause all applicable provisions of this Contract to be included in and made a part of
any contract or subcontract executed in the performance of its obligations hereunder including its
obligations regarding the HOPWA Regulations. Agency shall monitor the services and work
performed by its contractors, subcontractors and vendors on a regular basis for compliance with the
HOPWA Regulations and Contract provisions. Agency must cure all violations of the HOPWA
Regulations committed by its contractors, subcontractors or vendors. City maintains the right to
insist on Agency's full compliance with the terms of this Contract and the HOPWA Regulations and
Agency is responsible for such compliance regardless of whether actions taken to fulfill the
requirements of this Contract are taken by Agency or by Agency's contractors, subcontractors or
vendors. Agency acknowledges that the provisions of this Section shall survive the earlier
termination or expiration of this Contract and shall be applicable for 5 years after the Contract Term
ends.
7.9 Covvright and Patent Rights.
No reports, maps, or other documents produced in whole or in part under this Contract shall
be the subject of an application for copyright by or on behalf of Agency. HUD and City shall possess
HOPWA PSA CONTRACT 2023-2024 Page 9
Tarrant County Samaritan Housing, INC
Rev. 10-3-2023
all rights to invention or discovery, as well as rights in data, which may arise as a result of Agency's
performance under this Contract.
7.10 Conflict of Interest Disclosure.
In accordance with the requirements of Section 14.13.2.1 and 14.13.4, Agency shall establish
conflict of interest policies for federal awards. Agency shall disclose to City in writing any potential
conflict of interest.
7.11 Compliance with FFATA and Whistleblower Protections.
Agency shall comply with the requirements of 2 CFR 300(b), including provisions of the
Federal Funding Accountability and Transparency Act ("FFATA") governing requirements on
executive compensation and provisions governing whistleblower protections contained in 10 U.S.C.
2409, 41 U.S.C. 4712, 10 U.S.C. 2324, 41 U.S.C. 4304 and 41 U.S.C. 4310.
7.11.1 Agency shall provide City with its DUNS number.
7.12 Internal Controls.
In compliance with the requirements of 2 CFR Part 200.303, Agency shall:
7.12.1 Establish and maintain effective internal control over the HOPWA Funds that
provides reasonable assurance that Agency is managing the HOPWA Funds in compliance with
federal statutes, regulations, and the terms and conditions of this Contract. These internal controls
shall be in compliance with guidance in "Standards for Internal Control in the Federal Government"
issued by the Comptroller General of the United States or the "Internal Control Integrated
Framework" issued by the Committee of Sponsoring Organizations of the Treadway Commission
("COSO");
7.12.2 Comply with federal statutes, regulations, and the terms and conditions of this
Contract;
7.12.3 Evaluate and monitor Agency's compliance with statutes, regulations and the terms
and conditions of this Contract;
7.12.4 Take prompt action when instances of noncompliance are identified including
noncompliance identified in audit findings; and
7.12.5 Take reasonable measures to safeguard protected personally identifiable information
and other information that HUD or City designates as sensitive or Agency considers sensitive
consistent with applicable federal, state, local and tribal laws regarding privacy and obligations of
confidentiality.
7.13 Required Certification of Completion of Training.
At least 1 Agency employee must complete the HUD required "Getting to Work Training
Curriculum" by April 15, 2024 and submit the required certifications to City with the April 2024
Reimbursement Request as more particularly described on EXHIBIT "A-2" — Requirements for
Completion of "Getting to Work Training Curriculum".
HOPWA PSA CONTRACT 2023-2024 Page 10
Tarrant County Samaritan Housing, INC
Rev. 10-3-2023
7.14 National Standards for the Physical Inspection of Real Estate (NSPIRE).
All housing assisted under this Contract must be safe, habitable inside and outside of the
building, and within the units of HUD housing, must be functionally adequate, operable, and free of
health and safety hazards as required by 24 CFR §5.703, §574.310(b), 2, (2i and 2ii), (3), (4),(5),
and (8), §574.635, §35 and CPD-94-05. City shall have the right to inspect to confirm compliance
with these standards.
7.15. Violence Against Women Act Requirements
7.15.1 Agency shall comply with the Violence Against Women Act ("VAWA") and shall
ensure that any property owner, manager, or facility assisted by the HOPWA Funds shall, at the time
of application for services, provide all clients receiving rental assistance with a Notice of Occupancy
Rights under the Violence Against Women Act in substantially the same form as the form attached
and incorporated as Exhibit "L"-Notice of Occupancy Rights Under VAWA in compliance with
VAWA and 24 CFR Part 574.604(a)(2), where applicable.
7.15.2 Agency agrees that no applicant for HOPWA assistance may be denied admission or
assistance under the Program on the basis or as a direct result of the fact that they are or have been
a victim of domestic violence, dating violence, sexual assault, or stalking, as long as they would
otherwise qualify for the Program.
7.15.3 Agency shall be responsible for reviewing VAWA and 24 CFR Part 574.604 and shall
respond to all emergency transfer requests in accordance with the requirements of those
provisions. Agency may request that all clients requesting an emergency transfer under VAWA fill
out the form attached and incorporated as Exhibit "M" — VAWA Emergency Transfer Request
Form.
7.15.4 Agency shall document and report to City any VAWA emergency transfer request
and outcome in compliance with 24 CFR Part 91.520 and 24 CFR Part 574
8. RECORD KEEPING; REPORTING AND DOCUMENTATION REOUIREMENTS.
AUDIT.
8.1 Record Keeping.
Agency shall maintain a record -keeping system as part of its performance of this Contract
and shall promptly provide City with copies of any document City deems necessary for the effective
fulfillment of City's monitoring and evaluation responsibilities. Specifically, Agency will keep or
cause to be kept an accurate record of all actions taken and all funds spent, with supporting and back-
up documentation. Agency will maintain all records and documentation related to this Contract for
5 years after the Contract term ends. If any claim, litigation, or audit is initiated before the expiration
of the 5 year period, the relevant records and documentation must be retained until all such claims,
litigation or audits have been resolved. For purposes of this Contract, unless this Contract is earlier
terminated, this 5 year period for record retention is deemed to begin on October 1, 2024, or October
1, 2025 if the Contract is extended, and shall end no later than September 30, 2030.
HOPWA PSA CONTRACT 2023-2024 Page 11
Tarrant County Samaritan Housing, INC
Rev. 10-3-2023
8.2 Access to Records.
Representatives of City, HUD and any duly authorized officials of the federal government
will have full access to, and the right to examine, audit, copy, excerpt and/or transcribe any of
Agency's records pertaining to all matters covered by this Contract for 5 years after the Contract
term ends. Such access shall be during regular business hours and upon at least 48 hours prior notice.
For purposes of this Contract, unless this Contract is earlier terminated, this 5 year period for access
to records is deemed to begin on October 1, 2024, or October 1, 2025 if the Contract is extended,
and shall end no later than September 30, 2030.
8.3 Reports.
Agency will submit to City all reports and documentation described in this Contract in such
form as City may prescribe. Agency may also be required to submit a final performance and/or final
financial report if required by City at the termination of this Contract in such form and within such
times as City may prescribe. Failure to submit to City any report or documentation described in this
Contract shall be an event of default of this Contract and City may exercise all of its remedies for
default under this Contract.
8.3.1 Additional Information.
Agency shall provide City with additional information as may be required by state or federal
agencies to substantiate Program activities and/or expenditure eligibility.
8.4 Change in Reporting Requirements and Forms
City retains the right to change reporting requirements and forms at its discretion. City will
notify Agency in writing at least 15 days prior to the effective date of such change, and the Parties
shall execute an amendment to the Contract reflecting such change if necessary.
8.5 Audit
8.5.1 Entities that Expend $750,000 or more in Federal Funds Per Year
All non-federal entities that expend $750,000 or more in federal funds within 1 year,
regardless of the source of the federal award, must submit to City an annual audit prepared in
accordance with specific reference to 2 CFR Part 200.501 through Part 200.521. The audit shall
cover the Agency's fiscal years during which this Contract is in force. The audit must be prepared
by an independent certified public accountant, be completed within 6 months following the end of
the period being audited and be submitted to City within 30 days of its completion. Agency's audit
certification is attached hereto as EXHIBIT "C" — "Audit Certification Form" and "Audit
Requirements". The Audit Certification Form must be submitted to City prior to or with the first
Reimbursement Request. Entities that expend less than $750,000 a year in federal funds are exempt
from federal audit requirements for that year, but records must be available for review or audit by
appropriate officials of the federal agency, City, and General Accounting Office.
HOPWA PSA CONTRACT 2023-2024 Page 12
Tarrant County Samaritan Housing, INC
Rev. 10-3-2023
8.5.2 Citv Reserves the Right to Audit.
City reserves the right to perform an audit of Agency's Program operations and finances at
any time during the term of this Contract and for 5 years after the Contract Term ends if City
determines that such audit is necessary for City's compliance with the HOPWA Regulations or other
City policies. Agency agrees to allow access to all pertinent materials as described herein for such
audit. For purposes of this Contract, unless this Contract is earlier terminated, this 5 year period for
City audit is deemed to begin on October 1, 2024, or October 1, 2025 if the Contract is extended,
and shall end no later than September 30, 2030. If such audit reveals a questioned practice or
expenditure, such questions must be resolved within 15 business days after notice to Agency of such
questioned practice or expenditure. If questions are not resolved within this period, City reserves
the right to withhold further funding under this Contract and/or any other contracts with Agency. IF
AS A RESULT OF ANY AUDIT IT IS DETERMINED THAT AGENCY HAS FALSIFIED
ANY DOCUMENTATION OR MISUSED, MISAPPLIED OR MISAPPROPRIATED
HOPWA FUNDS OR SPENT HOPWA FUNDS ON ANY INELIGIBLE ACTIVITIES,
AGENCY AGREES TO REIMBURSE CITY THE AMOUNT OF SUCH MONIES PLUS
THE AMOUNT OF ANY SANCTIONS, PENALTY OR OTHER CHARGE LEVIED
AGAINST CITY BY HUD BECAUSE OF SUCH ACTIONS.
9. REIMBURSEMENT REOUIREMENTS
9.1 Deadline for Submitting Reimbursement Requests.
9.1.1 Reimbursement Requests shall be submitted monthly to the City and must be
received by the City on or before the 15th day of the month following the month expenses were paid
by Agency. For example, the Reimbursement Request for June expenses must be received by July
15. In the event the 15th falls on a weekend or City holiday, Reimbursement Requests shall be due
the next day that the City is open for business. Failure to submit a Reimbursement Request in a
timely fashion will result in City taking the actions outlined in Section 11.1.
NOTWITHSTANDING ANYTHING ABOVE, THE REIMBURSEMENT REQUEST FOR
EXPENSES INCURRED FOR SEPTEMBER 2024 MUST BE RECEIVED BY OCTOBER 1,
2024. COMPLETE DOCUMENTATION FOR ALL SEPTEMBER 2024 EXPENSES MUST
BE SUBMITTED BY OCTOBER 15, 2024. FAILURE TO SUBMIT A FINAL
REIMBURSEMENT REQUEST WITH COMPLETE DOCUMENTATION BY OCTOBER
15, 2024 WILL RESULT IN FORFEITURE OF PAYMENT OF THE SEPTEMBER
REIMBURSEMENT REQUEST.
9.1.2 City will notify Agency by e-mail within 14 calendar days if a Reimbursement
Request is lacking Complete Documentation or corrections are needed. Agency will have 7 business
days from the date of the e-mail notice to submit any requested information or missing
documentation. Agency may be penalized, at City's sole discretion, in the Request for Proposal for
the 2024-2025 Program Year for any notifications received under this Section. If Agency fails to
submit all the required information or missing documentation within 30 calendar days from the first
e-mail, Agency shall forfeit any payments otherwise due that month and failure to submit any
requested information will be considered an event of default as outlined in Section 10.1.2.
HOPWA PSA CONTRACT 2023-2024 Page 13
Tarrant County Samaritan Housing, INC
Rev. 10-3-2023
9.2 Submission of Reimbursement Requests.
Agency shall provide City with Complete Documentation and the following reports as shown
in EXHIBIT "D" — Reimbursement Forms with each Reimbursement Request:
9.2.1 Attachment I — Request Summary
This report shall contain the amount requested for reimbursement each month, the
cumulative reimbursement requested to date (inclusive of that month's request).
9.2.1.1 Agency must submit a separate invoice for each activity type, i.e.
Administration, Facility Based Operating Costs, Supportive Services,
Short-term Rent, Mortgage and Utility Assistance ("STRMU"), and
Tenant Based Rental Assistance ("TBRA").
9.2.2 Attachment II — Expenditure Worksheet
This report shall itemize each expense requested for reimbursement by Agency and shall
include the Account corresponding the expense to a Budget line item. In order for this report to be
complete the following must be submitted:
9.2.2.1 For payroll expenses, timesheets signed by employees and approved by
supervisor for all payroll expenses listed. Timesheets must distinguish
between HOPWA-funded time and non-HOPWA funded time and reflect
actual time spent on HOPWA-funded activities. Agency may not submit
payroll expenses dated 60 calendar days prior to the date of the
Reimbursement Request.
9.2.2.2 For non -payroll expenses, invoices for each expense listed with an
explanation as to how the invoiced expense pertains to the Program.
Agency may not submit invoices dated 60 calendar days prior to the date
of the Reimbursement Request.
9.2.2.3 Proof that each expense was paid by Agency, which proof can be satisfied
by canceled checks, wire transfer documentation, paid receipts or other
appropriate banking documentation.
9.2.3 Attachment III — Client Data Report.
This report shall list each Unduplicated Client served during the month along with his or her
demographic information. The Client Data Report must maintain a list of all clients served during
the Contract term. If Agency, receives funds from the United States Department of Justice or the
Victims of Crime Act, then Agency is prohibited from submitting the Client Data Report to the City.
However, Agency must complete all required forms under Section 9.2.3 and maintain in client files
in accordance with Section 8. In order for this report to be complete, the following must be
submitted:
9.2.3.1 Documentation of income verification for each Unduplicated Client the
first time the client is served by the Program, which will be Source
Documentation.
HOPWA PSA CONTRACT 2023-2024 Page 14
Tarrant County Samaritan Housing, INC
Rev. 10-3-2023
9.2.4 Overview Report.
Agency shall submit the Overview, Report, attached hereto as EXHIBIT "H" — Overview
Report, quarterly with the December, March, June and September Reimbursement Requests.
9.2.5 Delivery of Reimbursement Request.
Reimbursement Requests will be submitted through Neighborly Software on the
designated due date.
9.3 Withholding Pavment.
CITY SHALL HAVE NO OBLIGATION TO PAY ANY REIMBURSEMENT
REQUEST THAT IS NOT RECEIVED BY THE DUE DATE. Failure to timely submit
accurate and complete Reimbursement Requests and Complete Documentation along with any
required reports shall be an event of default.
10. DEFAULT AND TERMINATION.
10.1 Failure to Submit Reimbursement Request or Required Documentation.
10.1.1 If Agency fails to submit a Reimbursement Request in accordance with Section
9, Agency shall be in default of this Contract. City will notify Agency in writing of such default and
the Agency will have 7 calendar days from the date of the written notice to submit such
Reimbursement Request to cure the default. If Agency fails to cure the default within such time,
Agency shall forfeit any payments otherwise due that month.
10.1.2 If Agency fails to submit requested information or missing documentation as set
forth in Section 9.1.2, then Agency shall forfeit payment due that month and the failure to submit
shall be considered an event of default that shall not be cured.
10.1.3 NOTWITHSTANDING THE PROVISIONS OF SECTION 10.1.1 OR
10.1.2, IF AGENCY FAILS TO SUBMIT THE REIMBURSEMENT REQUEST DUE
OCTOBER 1, 2024, OR IF THE SUBMITTED REIMBURSEMENT REQUEST FOR
OCTOBER 1, 2024 IS LATE, INCOMPLETE OR OTHERWISE NOT IN COMPLIANCE
WITH THIS CONTRACT OR THE HOPWA REGULATIONS AS DETERMINED BY
CITY IN ITS SOLE DISCRETION, THERE WILL BE NO CURE PERIOD AND ANY
REIMBURSEMENT WILL BE FORFEITED.
10.1.4 In the event of (i) an uncured default under Section 10.1.1 or an event of default
under 10.1.2 (ii) or more than 2 instances of default, cured or uncured, under these Sections, City
reserves the right at its sole option to terminate this Contract effective immediately upon written
notice of such intent with no penalty or liability to City.
10.1.5 Notwithstanding anything to the contrary herein, City will not be required to pay
any HOPWA Funds to Agency during the period that any Reimbursement Request, report or
documentation is past due or is not in compliance with this Contract or the HOPWA Regulations, or
during any period during which Agency is in default of this Contract.
HOPWA PSA CONTRACT 2023-2024 Page 15
Tarrant County Samaritan Housing, INC
Rev. 10-3-2023
10.1.6 In the event of termination under this Section 10.1, all HOPWA Funds awarded
but unpaid to Agency pursuant to this Contract shall be immediately forfeited and Agency shall have
no further right to such funds.
10.2 Failure to Maintain Records or Submit Reports and Documentation.
If Agency fails to maintain all records and documentation as required in Section 8, or if the
maintained or submitted report or documentation is not in compliance with this Contract or the
HOPWA Regulations as determined by City in its sole discretion, City will notify Agency in writing
and Agency will have 30 calendar days from the date of the written request to obtain or recreate the
missing records and documentation or submit or resubmit any such report or documentation to City.
If Agency fails to maintain the required reports or documentation, or fails to submit or resubmit any
such report or documentation within such time, City shall have the right to terminate this Contract
effective immediately upon written notice of such intent with no penalty or liability to City.
10.2.1 In the event of termination under this Section 10.2, all HOPWA Funds awarded
but unpaid to Agency pursuant to this Contract shall be immediately forfeited and Agency shall have
no further right to such funds, and any HOPWA Funds paid to Agency must be repaid to City within
30 days of termination. If such HOPWA funds are not repaid to City within the 30 day period, City
shall exercise all legal remedies available under this Contract.
10.3 In General.
10.3.1 Subject to Section 10.2, and unless specifically provided otherwise in this
Contract, Agency shall be in default under this Contract if Agency breaches any term or condition
of this Contract. In the event that such a breach remains uncured after 30 calendar days following
written notice by City (or such other notice period as may be specified herein) or, if Agency has
diligently and continuously attempted to cure following receipt of such written notice but reasonably
requires more than 30 calendar days to cure, as determined by both Parties mutually and in good
faith, City shall have the right to elect in City's sole discretion to (i) extend Agency's time to cure,
(ii) terminate this Contract effective immediately upon written notice of such intent to Agency, or
(iii) pursue any other legal remedies available to City under this Contract.
10.3.2 City's remedies may include:
10.3.2.1 Direct Agency to prepare and follow a schedule of actions for carrying
out the affected activities, consisting of schedules, timetables and
milestones necessary to implement the affected activities.
HOPWA PSA CONTRACT 2023-2024 Page 16
Tarrant County Samaritan Housing, INC
Rev. 10-3-2023
10.3.2.2 Direct Agency to establish and follow a management plan that assigns
responsibilities for carrying out the remedial activities.
10.3.2.3 Reprogram HOPWA Funds that have not yet been expended from
affected activities to other eligible activities or withhold HOPWA
Funds.
10.3.2.4 Any other appropriate action including but not limited to any remedial
action legally available such as declaratory judgment, specific
performance, damages, temporary or permanent injunctions,
termination of this Contract or any other contracts with Agency, and
any other available remedies.
10.3.3 In the event of termination under this Section 10.3, all HOPWA Funds awarded
but unpaid to Agency pursuant to this Contract shall be immediately forfeited and Agency shall have
no further right to such funds, and any HOPWA Funds already paid to Agency must be repaid to
City within 30 days of the termination. Failure to repay such HOPWA Funds within the 30 day
period will result in City exercising all legal remedies available under this Contract.
10.4 No Funds Disbursed while in Breach.
Agency understands and agrees that no HOPWA Funds will be paid to Agency until all
defaults are cured to City's satisfaction.
10.5 No Compensation After Date of Termination.
Agency shall not receive any compensation for work undertaken after the date of the
termination.
10.6 Rights of Citv Not Affected.
Termination shall not affect or terminate any of the existing rights of City against Agency,
or which may thereafter accrue because of Agency's default and this provision shall be in addition
to any and all other rights and remedies available to City under the law. Such termination does not
terminate any provisions of this Contract that have been expressly noted as surviving the term or
termination of the Contract. No delay or omission by City in exercising any right or remedy
available to it under this Contract shall impair any such right or remedy or constitute a waiver or
acquiescence in any Agency default.
10.7 Waiver of Breach Not Waiver of Subsequent Breach
The waiver of a default or breach of any term, covenant, or condition of this Contract shall
not operate as a waiver of any subsequent default or breach of the same or any other term, covenant
or condition hereof.
10.8 Civil, Criminal and Administrative Penalties
Failure to perform all the Contract terms may result in civil, criminal or administrative
penalties, including, but not limited to those set out in this Contract.
HOPWA PSA CONTRACT 2023-2024 Page 17
Tarrant County Samaritan Housing, INC
Rev. 10-3-2023
10.9 Termination for Cause
10.9.1 City may terminate this Contract in the event of Agency's default, inability, or
failure to perform subject to notice, grace and cure periods. In the event City terminates this Contract
for cause, all HOPWA Funds awarded but unpaid to Agency pursuant to this Contract shall be
immediately rescinded and Agency shall have no further right to such funds and any HOPWA Funds
already paid to Agency must be repaid to City within 30 days of termination. Failure to repay such
HOPWA Funds within 30 days will result in City exercising all legal remedies available to City
under this Contract. AGENCY ACKNOWLEDGES AND AGREES THAT IF CITY
TERMINATES THIS CONTRACT FOR CAUSE, AGENCY OR ANY AFFILIATES OF
AGENCY SHALL NOT BE CONSIDERED FOR ANY OTHER CITY CONTRACT FOR
HOPWA FUNDS FOR A MINIMUM OF 5 YEARS FROM THE DATE OF TERMINATION.
11.9.2 Agency may terminate this Contract if City does not provide the HOPWA Funds
substantially in accordance with this Contract.
10.10 Termination for Convenience.
In terminating in accordance with 2 CFR Part 200, Appendix II, this Contract may be
terminated in whole or in part only as follows:
10.10.1 By City with the consent of Agency in which case the Parties shall agree upon
the termination conditions, including the effective date and in the case of partial termination, the
portion to be terminated; or
10.10.2 By Agency upon at least 30 days written notification to City, setting forth the
reasons for such termination, the effective date, and in the case of partial termination, the portion to
be terminated. In the case of a partial termination, City may terminate the Contract in its entirety if
City determines in its sole discretion that the remaining portion of the Contract to be performed or
HOPWA Funds to be spent will not accomplish the purposes for which the Contract was made.
10.11 Dissolution of A2encv Terminates Contract.
This Contract shall terminate in the event Agency is dissolved or ceases to exist. In the event
of termination under this Section, all HOPWA Funds are subject to repayment and/or City may
exercise all of its remedies under this Contract.
10.13 Reversion of Assets.
In the event this Contract is terminated with or without cause, all assets acquired by Agency
with the HOPWA Funds including cash, interest payments from loans or otherwise, all outstanding
notes, mortgages or other security instruments, any accounts receivable attributable to the use of the
HOPWA Funds, and any real or personal property owned by Agency that was improved with the
HOPWA Funds shall automatically transfer to City or to such assignee as City may designate.
11. REPAYMENT OF HOPWA FUNDS.
HOPWA PSA CONTRACT 2023-2024 Page 18
Tarrant County Samaritan Housing, INC
Rev. 10-3-2023
All HOPWA Funds are subject to repayment in the event the Program does not meet the
requirements of this Contract or in the HOPWA Regulations. If Agency takes any action that
results in the City being required to repay all or any portion of the HOPWA Funds to HUD,
Agency agrees it will reimburse City within thirty days of notice from the City for such
repayment. Additionally, if Agency takes any action that results in City receiving a finding
from HUD about the Program, whether or not repayment of all or any portion of the HOPWA
Funds is required of City, Agency agrees City may require that 10% of the HOPWA Funds be
repaid to City as liquidated damages. The Parties agree that City's damages in the event of either
repayment to HUD being required or receiving a finding from HUD are uncertain and would be
difficult to ascertain and may include an impact on City's HOPWA grant or other federal grant funds,
in addition to the finding by HUD or a required repayment of funds to HUD by City. Therefore, the
Parties agree that payment under this Section of 10% of the HOPWA Funds by Agency to City is
liquidated damages and not a penalty.
12. CHANGE IN NON-PROFIT STATUS.
Agency must provide City with written notification of any changes to its non-profit status
within 15 calendar days of being notified of the change. Regardless of notice by Agency, if the non-
profit status of Agency changes after the date of this Contract, City may but is not obligated to,
terminate this Contract. In the event of termination under this Section 12, all HOPWA Funds
awarded but not yet paid to Agency pursuant to this Contract shall be immediately rescinded and
Agency shall have no further right to such funds. City, in its sole discretion, may require that any
HOPWA Funds already paid to Agency must be repaid to City within 30 calendar days of
termination under this Section.
13. SURVIVAL.
Any provision of this Contract that pertains to auditing, monitoring, indemnity obligations,
client income eligibility, record keeping and reports, City ordinances, or applicable HOPWA
requirements, and any default and enforcement provisions necessary to enforce such provisions,
shall survive the termination of this Contract for 5 years after the Contract term ends and shall be
enforceable by City against Agency. For purposes of this Contract, unless this Contract is earlier
terminated, this 5 year period for survival of certain Contract provisions is deemed to begin on
October 1, 2024, or October 1, 2025, if this contract is extended and end no later than September
30, 2030.
14. GENERAL PROVISIONS.
14.1 ALencv an Independent Contractor.
Agency shall operate hereunder as an independent contractor and not as an officer, agent,
servant or employee of City. Agency shall have exclusive control of, and the exclusive right to
control, the details of the work and services performed hereunder, and all persons performing same,
and shall be solely responsible for the acts and omissions of its officers, members, agents, servants,
employees, contractors, subcontractors, vendors, clients, licensees or invitees.
14.2 Doctrine of Resvondeat Superior.
The doctrine of respondeat superior shall not apply as between City and Agency, or its
HOPWA PSA CONTRACT 2023-2024 Page 19
Tarrant County Samaritan Housing, INC
Rev. 10-3-2023
officers, members, agents, servants, employees, contractors, subcontractors, vendors, clients,
licensees or invitees, and nothing herein shall be construed as creating a partnership or joint
enterprise between City and Agency. City does not have the legal right to control the details of the
tasks performed hereunder by Agency, its officers, members, agents, employees, contractors,
subcontractors, vendors, clients, licensees or invitees.
14.3 Agency Property.
City shall under no circumstances be responsible for any property belonging to Agency, or
its officers, members, agents, employees, contractors, subcontractors, vendors, clients, licensees or
invitees that may be lost, stolen or destroyed or in any way damaged and AGENCY HEREBY
INDEMNIFIES AND HOLDS HARMLESS CITY AND ITS OFFICERS, AGENTS, AND
EMPLOYEES FROM ANY AND ALL CLAIMS OR SUITS PERTAINING TO OR
CONNECTED WITH SUCH PROPERTY.
14.5 Religious Organization.
Agency shall comply with all applicable requirements as more particularly described in 24
CFR Part 5.109. No portion of the HOPWA Funds shall be used in support of any sectarian or
religious activity. In addition, there must be no religious or membership criteria for clients of a
HOPWA-funded service.
14.5.1. Separation of Explicitly Religious Activities.
Agency retains its independence and may continue to carry out its mission, including the
definition, development practice, and expression of its religious beliefs, provided that it does not use
HOPWA Funds to support or engage in any explicitly religious activities (including activities that
involve overt religious content such as worship, religious instruction, or proselytization), or in any
other manner prohibited by law.
14.5.2 Explicitly Religious Activities.
If Agency engages in explicitly religious activities (including activities that involve overt
religious content such as worship, religious instruction, or proselytization), the explicitly religious
activities must be offered separately, in time or location, from the programs or activities supported
by HOPWA Funds and participation must be voluntary for clients of a HOPWA-funded service.
14.5.3 Required Notices.
If Agency constitutes a Faith -based organization under 24 CFR Part 5.109, Agency must
provide all clients of a HOPWA-funded service with the notice attached as EXHIBIT "K"—Notice
of Beneficiary Rights. Such notice shall be provided to the client prior to enrollment in any
HOPWA-funded program or activity. In addition, if a client or prospective client of a HOPWA-
funded service objects to the religious character of Agency, then Agency must promptly undertake
reasonable efforts to identify and refer the client or prospective client to an alternate provider to
which the client or prospective client has no such objection, as more particularly described in 24
CFR Part 5.109.
HOPWA PSA CONTRACT 2023-2024 Page 20
Tarrant County Samaritan Housing, INC
Rev. 10-3-2023
14.6 Venue.
Venue shall lie in state courts located in Tarrant County, Texas or the United States District Court
for the Northern District of Texas, Fort Worth Division for any action, whether real or asserted, at law
or in equity, arising out of the execution, performance, attempted performance or non-performance
of this Contract.
14.7 Governing Law.
This Contract shall be governed by and construed in accordance with the laws of the State of
Texas. If any action, whether real or asserted, at law or in equity, arises out of the execution,
performance or non-performance of this Contract or on the basis of any provision herein, for any
issue not governed by federal law, the choice of law shall be the laws of the State of Texas.
14.8 Severabilitv.
The provisions of this Contract are severable, and if for any reason a clause, sentence,
paragraph or other part of this Contract shall be determined to be invalid by a court or federal or
state agency, board or commission having jurisdiction over the subject matter thereof, such invalidity
shall not affect other provisions which can be given effect without the invalid provision.
14.9 Written Agreement Entire Contract.
This written instrument and the Exhibits, Attachments, and Addendums attached hereto,
which are incorporated by reference and made a part of this Contract for all purposes, constitute the
entire agreement by the Parties concerning the work and services to be performed under this
Contract. Any prior or contemporaneous oral or written agreement which purports to vary the terms
of this Contract shall be void. Any amendments to the terms of this Contract must be in writing and
executed by the Parties.
14.10 Paragraph Headings for Reference Only. No Legal Significance; Number
and Gender.
The paragraph headings contained herein are for convenience in reference to this Contract
and are not intended to define or to limit the scope of any provision of this Contract. When context
requires, singular nouns and pronouns include the plural and the masculine gender shall be deemed
to include the feminine or neuter and the neuter gender to include the masculine and feminine. The
words "include" and "including" whenever used herein shall be deemed to be followed by the words
"without limitation".
14.11 Compliance With All Applicable Laws and Regulations.
Agency agrees to comply fully with all applicable laws and regulations that are currently in
effect or that are hereafter amended during the performance of this Contract. Those laws include,
but are not limited to:
➢ HOPWA Regulations found in 24 CFR Part 574
➢ AIDS Housing Opportunity Act, as amended (42 USC 12901 et seq.)
➢ Title VI of the Civil Rights Act of 1964 (42 U.S.C. Sections 2000d et seq.) including
provisions requiring recipients of federal assistance to ensure meaningful access by
persons of limited English proficiency
HOPWA PSA CONTRACT 2023-2024 Page 21
Tarrant County Samaritan Housing, INC
Rev. 10-3-2023
➢ The Fair Housing Act, Title VIII of the Civil Rights Act of 1968 (42 U.S.C. Sections
3601 et seq.)
➢ Executive Orders 11063, 11246 as amended by 11375 and 12086 and as supplemented
by Department of Labor regulations 41 CFR Part 60
➢ The Age Discrimination in Employment Act of 1967
➢ The Age Discrimination Act of 1975 (42 U.S.C. Sections 6101 et seq.)
➢ The Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970
(42 U.S.C. Sections 4601 et seq. and 49 CFR Part 24) ("URA")
➢ Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. Sections 794 et seq.) and 24
CFR Part 8 where applicable
➢ National Environmental Policy Act of 1969, as amended, 42 U.S.C. Sections 4321 et seq.
("NEPA") and the related authorities listed in 24 CFR Part 58.
➢ The Clean Air Act, as amended, (42 U.S.C. Sections 1251 et seq.) and the Clean Water
Act of 1977, as amended (33 U.S.C. Sections 1251 et seq.) and the related Executive
Order 11738. In no event shall any amount of the assistance provided under this Contract
be utilized with respect to a facility that has given rise to a conviction under the Clean
Air Act or the Clean Water Act.
➢ Immigration Reform and Control Act of 1986 (8 U.S.C. Sections 1101 et seq.)
specifically including the provisions requiring employer verifications of legal status of
its employees
➢ The Americans with Disabilities Act of 1990 (42 U.S.C. Sections 12101 et seq.), the
Architectural Barriers Act of 1968 as amended (42 U.S.C. Sections 4151 et seq.) and the
Uniform Federal Accessibility Standards, 24 CFR Part 40, Appendix A
➢ Regulations at 24 CFR Part 87 related to lobbying, including the requirement that
certifications and disclosures be obtained from all covered persons
➢ Drug Free Workplace Act of 1988 (41 U.S.C. Sections 701 et seq.) and 24 CFR Part 23,
Subpart F
➢ Executive Order 12549 and 24 CFR Part 5.105(c) pertaining to restrictions on
participation by ineligible, debarred or suspended persons or entities
➢ Section 6002 of the Solid Waste Disposal Act, as amended by the Resource Conservation
and Recovery Act
➢ Guidelines of the Environmental Protection Agency at 40 CFR Part 247
➢ For contracts and subgrants for construction or repair, Copeland "Anti -Kickback" act (18
U.S.C. 874) as supplemented in 29 CFR Part 5
➢ For construction contracts awarded by Agency in excess of $2,000, and in excess of
$2,500 for other contracts which involve the employment of mechanics or laborers,
Sections 103 and 107 of the Contract Work Hours and Safety Standards Act (40 U.S.C.
327A 300) as supplemented by 29 CFR Part 5
➢ Lead -Based Paint Poisoning Prevention Act (42 U.S.C. 4801 et seq.), as amended by the
Residential Lead -Based Paint Hazard Reduction Act of 1992 (42 U.S.C. 4851 et seq.)
and implementing regulations at 24 CFR Part 35, subparts A, B, M, and R
➢ Uniform Administrative Requirements, Cost Principles, and Audit Requirements for
Federal Awards, 2 CFR Part 200 et seq.
➢ Federal Funding Accountability and Transparency Act of 2006 ("FFATA") (Pub.L. 109-
282, as amended by Section 6205(a) of Pub.L. 110-252 and Section 3 of Pub.L. 113-101)
➢ Federal Whistleblower Regulations, as contained in 10 U.S.C. 2409, 41 U.S.C. 4712, 10
HOPWA PSA CONTRACT 2023-2024 Page 22
Tarrant County Samaritan Housing, INC
Rev. 10-3-2023
U.S.C. 2324, 41 U.S.C. 4304 and 41 U.S.C. 4310.
14.12 H D Assisted PFoiealJ and Emplovment and—otheilKeoiivomie
Opportunitiesi aeetion 3 Re emend
14.13 Prohibition Against Discrimination.
14.13.1 General Statement.
Agency shall comply in the execution, performance or attempted performance of this
Contract, with all non-discrimination requirements of 24 CFR Part 574.603 and Chapter 17, Article
III, Division 4 — Fair Housing of the City Code. Agency may not discriminate against any person
because of race, color, sex, gender, religion, national origin, familial status, disability or perceived
disability, sexual orientation, gender identity, gender expression, or transgender, nor will Agency
permit its officers, members, agents, employees, or clients to engage in such discrimination.
This Contract is made and entered into with reference specifically to Chapter 17, Article III,
Division 3 - Employment Practices of the City Code, and Agency hereby covenants and agrees that
Agency, its officers, members, agents, employees and contractors, have fully complied with all
provisions of same and that no employee, or applicant for employment has been discriminated
against under the terms of such ordinances by either or its officers, members, agents, employees or
contractors.
14.13.2 No Discrimination in Emplovment during the Performance of This Contract.
During the performance of this Contract Agency agrees to the following provision, and will
require that its contractors and subcontractors also comply with such provision by including it in all
contracts with its contractors:
[Contractor's, Subcontractor's or Vendor's name] will not unlawfully discriminate against
any employee or applicants for employment because of race, color, sex, gender, religion, national
origin, familial status, disability or perceived disability, sexual orientation, gender identity, gender
expression or transgender. [Contractor's, Subcontractor's or Vendor's name]will take affirmative
action to ensure that applicants are hired without regard to race, color, sex, gender, religion, national
origin, familial status, disability or perceived disability, sexual orientation, gender identity, gender
expression or transgender and that employees are treated fairly during employment without regard
to their race, color, sex, gender, religion, national origin, familial status, disability or perceived
disability, sexual orientation, gender identity, gender expression or transgender. Such action shall
include, but not be limited to, the following: employment, upgrading, demotion or transfer,
recruitment or recruitment advertising, layoff or termination, rates of pay or other forms of
compensation, and selection for training, including apprenticeship. [Contractor's, Subcontractor's
or Vendor's name] agrees to post in conspicuous places, available to employees and applicants for
employment, notices setting forth the provisions of this nondiscrimination clause.
f Contractor's Subcontractor's or Vendor's name] will, in all solicitations or advertisements
for employees placed by or on behalf of [Contractor's, Subcontractor's or Vendor's name], state
that all qualified applicants will receive consideration for employment without regard to race, color,
sex, gender, religion, national origin, familial status, disability or perceived disability, sexual
orientation, gender identity, gender expression or transgender.
HOPWA PSA CONTRACT 2023-2024 Page 23
Tarrant County Samaritan Housing, INC
Rev. 10-3-2023
[Contractor's, Subcontractor's or Vendor's name] covenants that neither it nor any of its
officers, members, agents, employees, or contractors, while engaged in performing this Contract,
shall, in connection with the employment, advancement or discharge of employees or in connection
with the terms, conditions or privileges of their employment, discriminate against persons because
of their age or because of any disability or perceived disability, except on the basis of a bona fide
occupational qualification, retirement plan or statutory requirement.
[Contractor's. Subcontractor's or Vendor's name] further covenants that neither it nor its
officers, members, agents, employees, contractors, or persons acting on their behalf, shall specify,
in solicitations or advertisements for employees to work on this Contract, a maximum age limit for
such employment unless the specified maximum age limit is based upon a bona fide occupational
qualification, retirement plan or statutory requirement.
14.13.3 Agencv's Contractors and the ADA.
In accordance with the provisions of the Americans With Disabilities Act of 1990 ("ADA"),
Agency warrants that it and any of its contractors will not unlawfully discriminate on the basis of
disability in the provision of services to the general public, nor in the availability, terms and/or
conditions of employment for applicants for employment with, or employees of, Agency or any of
its contractors. AGENCY WARRANTS IT WILL FULLY COMPLY WITH THE ADA'S
PROVISIONS AND ANY OTHER APPLICABLE FEDERAL, STATE AND LOCAL LAWS
CONCERNING DISABILITY AND WILL DEFEND, INDEMNIFY AND HOLD CITY
HARMLESS AGAINST ANY CLAIMS OR ALLEGATIONS ASSERTED BY THIRD
PARTIES, CONTRACTORS SUBCONTRACTORS, VENDORS OR AGENTS AGAINST
CITY ARISING OUT OF AGENCY'S AND/OR ITS CONTRACTORS',
SUBCONTRACTORS', VENDORS' OR AGENTS' OR THEIR RESPECTIVE
EMPLOYEES' ALLEGED FAILURE TO COMPLY WITH THE ABOVE -REFERENCED
LAWS CONCERNING DISABILITY DISCRIMINATION IN THE PERFORMANCE OF
THIS CONTRACT.
14.14. Conflicts of Interest and Violations of Criminal Law.
14.14.1 Agencv Safeguards.
Agency shall establish safeguards to prohibit its employees, board members, advisors and
agents from using positions for a purpose that is or gives the appearance of being motivated by a
desire for private gain for themselves or others, particularly those with whom they have family,
business or other ties. Agency shall disclose to City any such conflict of interest or potential conflict
of interest, immediately upon discovery of such.
14.14.2 General Prohibitions Against Conflicts of Interest.
No employees, agents, consultants, officers or elected officials or appointed officials of City
or of Agency who exercise or have exercised any functions or responsibilities with respect to
activities assisted with HOPWA funds or who are in a position to participate in a decision -making
process or gain inside information with regard to these activities may utilize HOPWA services, may
obtain a financial interest or benefit from a HOPWA-assisted activity, or have an interest in any
contract, subcontract or agreement with respect thereto, or the proceeds thereunder, either for
HOPWA PSA CONTRACT 2023-2024 Page 24
Tarrant County Samaritan Housing, INC
Rev. 10-3-2023
themselves or those with whom they have family or business ties, during their tenure or for 1 year
thereafter.
14.14.2.1 Agency shall establish conflict of interest policies for federal awards
including the HOPWA Funds and shall disclose in writing potential
conflicts of interest to City as authorized by 2 CFR Part 200.112.
14.14.3 Conflicts of Interest Involving Procurement.
The conflict of interest provisions of 2 CFR Part 200.318, shall apply in the procurement of
property and services by Agency. In all cases not governed by those Sections, the provisions of 24
CFR Part 574.625 of the HOPWA Regulations shall apply.
14.14.3.1 As more particularly described in 2 CFR Part 200.318, Agency shall
maintain and submit to City written standards of conduct covering
conflicts of interest and governing the performance of its employees
engaged in the selection, award, and administration of contracts. No
employee, officer, or agent may participate in the selection, award, or
administration of a contract supported by a federal award if he or she
has a real or apparent conflict of interest. The standards of conduct
must provide for disciplinary actions to be applied for violations of
such standards by officers, employees, or agents of Agency.
14.14.3.2 The officers, employees, and agents of Agency shall neither solicit nor
accept gratuities, favors, or anything of monetary value from
contractors or parties to subcontracts.
14.14.3.3 Notwithstanding the prohibition contained in Section 14.13.3.2,
Agency may set standards of conduct for situations in which the
financial interest is not substantial or the gift is an unsolicited item of
nominal value. Such standards of conduct must provide for
disciplinary actions to be applied for violations of such standards by
Agency's officers, employees or agents.
14.14.3.4 Agency shall maintain written standards of conduct covering
organizational conflicts of interest. Organizational conflicts of
interest means that because of relationships with a parent company,
affiliate, or subsidiary organization, Agency is unable or appears to be
unable to be impartial in conducting a procurement action involving a
related organization.
14.14.3.5 Agency must maintain records sufficient to detail the history of
procurement. These records will include, but are not necessarily
limited to the following: rationale for the method of procurement,
selection of contract type, contractor selection or rejection, and the
basis for the contract price.
HOPWA PSA CONTRACT 2023-2024 Page 25
Tarrant County Samaritan Housing, INC
Rev. 10-3-2023
14.14.4 Disclosure of Conflicts of Interest.
In compliance with 2 CFR Part 200.112, Agency is required to timely disclose to City in
writing any potential conflict of interest.
14.14.5 Disclosure of Texas Penal Code Violations.
Agency affirms that it will adhere to the provisions of the Texas Penal Code which prohibit
bribery and gifts to public servants.
14.14.6 Disclosure of Federal Criminal Law Violations.
In compliance with 2 CFR Part 200.113, Agency is required to timely disclose to City all
violations of federal criminal law involving fraud, bribery or gratuity violations potentially affecting
the Agency.
14.15 Subcontracting with Small and Minority Firms, Women's Business
Enterprises and Labor Surplus Areas.
14.15.1 For procurement contracts $50,000.00 or larger that are paid for, in part or in full,
with HOPWA Funds, Agency agrees to abide by City's policy to involve Minority Business
Enterprises and Small Business Enterprises and to provide them equal opportunity to compete for
contracts for construction, provision of professional services, purchase of equipment and supplies
and provision of other services required by City. Agency agrees to incorporate the City's BDE
Ordinance, and all amendments or successor policies or ordinances thereto, into all contracts and
subcontracts for procurement larger than $50,000.00 or larger that are paid for, in part or in full, with
the HOPWA Funds and will further require all persons or entities with which it so contracts to
comply with said ordinance.
14.15.2 It is national policy to award a fair share of contracts to disadvantaged business
enterprises ("DBEs"), small business enterprises ("SBEs"), minority business enterprises
("MBEs"), and women's business enterprises ("WBEs"). Accordingly, affirmative steps must be
taken to assure that DBEs, SBEs, MBEs, and WBEs are utilized when possible as sources of
supplies, equipment, construction and services.
14.15.2.1 In order to comply with federal reporting requirements, Agency must
submit the form attached hereto as EXHIBIT "I" — MBE Reporting
Form for each contract or subcontract with a value of $10,000.00 or
more paid or to be paid with the HOPWA Funds. Agency shall submit
this form by the date specified in EXHIBIT "I" — MBE Reporting
Form.
14.16 Other Laws.
The failure to list any federal, state or City ordinance, law or regulation that is applicable to
Agency does not excuse or relieve Agency from the requirements or responsibilities in regard to
following the law, nor from the consequences or penalties for Agency's failure to follow the law, if
applicable.
HOPWA PSA CONTRACT 2023-2024 Page 26
Tarrant County Samaritan Housing, INC
Rev. 10-3-2023
14.17 Assignment.
Agency shall not assign all or any part of its rights, privileges, or duties under this Contract
without the prior written approval of City. Any attempted assignment of same without approval
shall be void, and shall constitute a breach of this Contract.
14.18. Right to Inspect Agency Contracts.
It is agreed that City has the right to inspect and approve in writing any proposed contracts
between Agency and any contractor or vendor engaged in any activity in conjunction with this
HOPWA-funded Program prior to any charges being incurred.
14.19 Force Maieure
If Agency becomes unable, either in whole or part, to fulfill its obligations under this Contract
due to acts of God, strikes, lockouts, or other industrial disturbances, acts of public enemies, wars,
blockades, insurrections, riots, epidemics, pandemics, earthquakes, fires, floods, restraints or
prohibitions by any court, board, department, commission or agency of the United States or of any
States, civil disturbances, or explosions, or some other reason beyond Agency's control (collectively,
"Force Majeure Event"), the obligations so affected by such Force Majeure Event will be
suspended only during the continuance of such event. Agency will give City written notice of the
existence, extent and nature of the Force Majeure Event as soon as reasonably possible after the
occurrence of the event. Failure to give notice will result in the continuance of Agency's obligation
regardless of the extent of any existing Force Majeure Event. Agency will use commercially
reasonable efforts to remedy its inability to perform as soon as possible.
14.20 IMMIGRATION NATIONALITY ACT.
Agency shall verify the identity and employment eligibility of its employees who perform
work under this Contract, including completing the Employment Eligibility Verification Form (I-
9). Upon request by City, Agency shall provide City with copies of all I-9 forms and supporting
eligibility documentation for each employee who performs work under this Contract. Agency shall
adhere to all Federal and State laws as well as establish appropriate procedures and controls so that
no services will be performed by any Agency employee who is not legally eligible to perform such
services. AGENCY SHALL INDEMNIFY CITY AND HOLD CITY HARMLESS FROM
ANY PENALTIES, LIABILITIES, OR LOSSES DUE TO VIOLATIONS OF THIS
PARAGRAPH BY AGENCY, AGENCY'S EMPLOYEES, SUBCONTRACTORS, AGENTS,
OR LICENSEES. City, upon written notice to Agency, shall have the right to immediately
terminate this Contract for violations of this provision by Agency.
15. INDEMNIFICATION AND RELEASE.
AGENCY COVENANTS AND AGREES TO INDEMNIFY, HOLD HARMLESS AND
DEFEND, AT ITS OWN EXPENSE, CITY AND ITS OFFICERS, AGENTS, SERVANTS
AND EMPLOYEES FROM AND AGAINST ANY AND ALL CLAIMS OR SUITS FOR
PROPERTY LOSS OR DAMAGE AND/OR PERSONAL INJURY, INCLUDING DEATH,
TO ANY AND ALL PERSONS, OF WHATSOEVER HIND OR CHARACTER, WHETHER
REAL OR ASSERTED, ARISING OUT OF OR IN CONNECTION WITH THE
EXECUTION, PERFORMANCE, ATTEMPTED PERFORMANCE OR
NONPERFORMANCE OF THIS CONTRACT AND/OR THE OPERATIONS, ACTIVITIES
HOPWA PSA CONTRACT 2023-2024 Page 27
Tarrant County Samaritan Housing, INC
Rev. 10-3-2023
AND SERVICES OF THE PROGRAM DESCRIBED HEREIN, WHETHER OR NOT
CAUSED IN WHOLE OR IN PART, BY ALLEGED NEGLIGENCE OF OFFICERS,
AGENTS, SERVANTS, EMPLOYEES, CONTRACTORS OR SUBCONTRACTORS OF
CITY; AND AGENCY HEREBY ASSUMES ALL LIABILITY AND RESPONSIBILITY OF
CITY AND ITS OFFICERS, AGENTS, SERVANTS, AND EMPLOYEES FOR ANY AND
ALL CLAIMS OR SUITS FOR PROPERTY LOSS OR DAMAGE AND/OR PERSONAL
INJURY, INCLUDING DEATH, TO ANY AND ALL PERSONS, OF WHATSOEVER
HINDS OR CHARACTER, WHETHER REAL OR ASSERTED, ARISING OUT OF OR IN
CONNECTION WITH THE EXECUTION, PERFORMANCE, ATTEMPTED
PERFORMANCE OR NONPERFORMANCE OF THIS CONTRACT AND/OR THE
OPERATIONS, ACTIVITIES AND SERVICES OF THE PROGRAM DESCRIBED
HEREIN, WHETHER OR NOT CAUSED IN WHOLE OR IN PART BY ALLEGED
NEGLIGENCE OF OFFICERS, AGENTS, SERVANTS, EMPLOYEES, CONTRACTORS
OR SUBCONTRACTORS OF CITY. AGENCY LIKEWISE COVENANTS AND AGREES
TO AND DOES HEREBY INDEMNIFY AND HOLD HARMLESS CITY FROM AND
AGAINST ANY AND ALL INJURY, DAMAGE OR DESTRUCTION OF PROPERTY OF
CITY, ARISING OUT OF OR IN CONNECTION WITH ALL ACTS OR OMISSIONS OF
AGENCY, ITS OFFICERS, MEMBERS, AGENTS, EMPLOYEES, CONTRACTORS,
SUBCONTRACTORS, INVITEES, LICENSEES, OR CLIENTS, OR CAUSED, IN WHOLE
OR IN PART, BY ALLEGED NEGLIGENCE OF OFFICERS, AGENTS, SERVANTS,
EMPLOYEES, CONTRACTORS OR SUBCONTRACTORS OF CITY.
IT IS THE EXPRESS INTENTION OF THE PARTIES, BOTH AGENCY AND CITY,
THAT THE INDEMNITY PROVIDED FOR THIS SECTION INCLUDES INDEMNITY BY
AGENCY TO INDEMNIFY AND PROTECT CITY FROM THE CONSEQUENCES OF
CITY'S OWN NEGLIGENCE, WHETHER THAT NEGLIGENCE IS ALLEGED TO BE
THE SOLE OR CONCURRING CAUSE OF THE INJURY, DAMAGE OR DEATH.
AGENCY AGREES TO AND SHALL RELEASE CITY, ITS AGENTS,
EMPLOYEES, OFFICERS AND LEGAL REPRESENTATIVES FROM ALL LIABILITY
FOR INJURY, DEATH, DAMAGE OR LOSS TO PERSONS OR PROPERTY SUSTAINED
IN CONNECTION WITH OR INCIDENTAL TO PERFORMANCE UNDER THIS
CONTRACT, EVEN IF THE INJURY, DEATH, DAMAGE OR LOSS IS CAUSED BY
CITY'S SOLE OR CONCURRENT NEGLIGENCE.
AGENCY SHALL REQUIRE ALL OF ITS CONTRACTORS AND
SUBCONTRACTORS TO INCLUDE IN THEIR CONTRACTS AND SUBCONTRACTS A
RELEASE AND INDEMNITY IN FAVOR OF CITY IN SUBSTANTIALLY THE SAME
FORM AS ABOVE.
16. WAIVER OF IMMUNITY BY AGENCY.
If Agency, as a charitable or nonprofit organization, has or claims an immunity or exemption
(statutory or otherwise) from and against liability for damages or injury, including death, to persons
or property, Agency hereby expressly waives its rights to plead defensively such immunity or
exemption as against City. This Section shall not be construed to affect a governmental entity's
HOPWA PSA CONTRACT 2023-2024 Page 28
Tarrant County Samaritan Housing, INC
Rev. 10-3-2023
immunities under constitutional, statutory or common law.
17. INSURANCE AND BONDING.
Agency will maintain coverage in the form of insurance or bond in the amount of
$1,300,000.00 to insure against loss from the fraud, theft or dishonesty of any of Agency's officers,
agents, trustees, directors or employees. The proceeds of such insurance or bond shall be used to
reimburse City for any and all loss of HOPWA Funds occasioned by such misconduct. To effectuate
such reimbursement, such fidelity coverage shall include a rider stating that reimbursement for any
loss or losses shall name the City as a Loss Payee.
Agency shall furnish to City in a timely manner, but not later than the Effective Date,
certificates of insurance as proof that it has secured and paid for policies of commercial insurance
as specified herein. If City has not received such certificates by the Effective Date, Agency shall be
in default of the Contract and City may, at its option, terminate the Contract.
Such insurance shall cover all insurable risks incident to or in connection with the execution,
performance, attempted performance or nonperformance of this Contract. Agency shall maintain
the following insurance coverage and limits:
Commercial General Liabilitv (CGL) Insurance
$ 500,000 each occurrence
$1,000,000 aggregate limit
Non -Profit Organization Liabilitv or Directors & Officers Liabilitv
$1,000,000 Each Occurrence
$1,000,000 Annual Aggregate Limit
Business Automobile Liabilitv Insurance
$1,000,000 each accident on a combined single -limit basis, or
$ 250,000 Property Damage
$ 500,000 Bodily Injury per person per occurrence
$2,000,000 Aggregate
Insurance policy shall be endorsed to cover "Any Auto", defined as autos owned, hired,
and non -owned. Pending availability of the above coverage and at the discretion of
City, the policy shall be the primary responding insurance policy versus a personal
auto insurance policy if or when in the course of Agency's business as contracted
herein.
Workers' Compensation Insurance
Part A: Statutory Limits
Part B: Employer's Liability
$100,000 each accident
$100,000 disease -each employee
HOPWA PSA CONTRACT 2023-2024 Page 29
Tarrant County Samaritan Housing, INC
Rev. 10-3-2023
$500,000 disease -policy limit
Note: Such insurance shall cover employees performing work on any and all projects
including but not limited to construction, demolition, and rehabilitation. Agency or its
contractors shall maintain coverages, if applicable. In the event the respective contractors
do not maintain coverage, Agency shall maintain the coverage on such contractor, if
applicable, for each applicable contract.
Additional Requirements
Such insurance amounts shall be revised upward at City's reasonable option and no more frequently
than once every 12 months, and Agency shall revise such amounts within 30 days following notice
to Contractor of such requirements.
Agency will submit to City documentation that it has obtained insurance coverage and has executed
bonds as required in this Contract prior to payment of any monies provided hereunder.
Where applicable, insurance policies required herein shall be endorsed to include City as an
additional insured as its interest may appear. Additional insured parties shall include employees,
officers, agents, and volunteers of City.
Any failure on part of City to request certificate(s) of insurance shall not be construed as a waiver
of such requirement or as a waiver of the insurance requirements themselves.
Insurers of Agency's insurance policies shall be licensed to do business in the state of Texas by the
Department of Insurance or be otherwise eligible and authorized to do business in the state of Texas.
Insurers shall be acceptable to City insofar as their financial strength and solvency and each such
company shall have a current minimum A.M. Best Key Rating Guide rating of A-: VII or other
equivalent insurance industry standard rating otherwise approved by City.
Deductible limits on insurance policies shall not exceed $5,000 per occurrence unless otherwise
approved by City.
In the event there are any local, federal or other regulatory insurance or bonding requirements for
the Program, and such requirements exceed those specified herein, the former shall prevail.
Agency shall require its contractors to maintain applicable insurance coverages, limits, and other
requirements as those specified herein; and Agency shall require its contractors to provide Agency
with certificate(s) of insurance documenting such coverage. Also, Agency shall require its
contractors to have City and Agency endorsed as additional insureds (as their interest may appear)
on their respective insurance policies.
Directors and Officers Liability coverage shall be in force and may be provided on a claims -made
basis. This coverage may also be referred to as Management Liability, and shall protect the insured
against claims arising out of alleged errors in judgment, breaches of duty and wrongful acts arising
out of their organizational duties. Coverage shall protect not only the entity, but all past, present and
future directors, officers, trustees, employees, volunteers and committee members.
HOPWA PSA CONTRACT 2023-2024 Page 30
Tarrant County Samaritan Housing, INC
Rev. 10-3-2023
Notwithstanding any provision in this Contract to the contrary, when applicable, Agency shall
comply with the requirements of 2 CFR 200.310 and shall, at a minimum, provide the
equivalent insurance coverage for real property and equipment acquired or improved with
HOPWA Funds as provided to property owned by Agency.
18. CERTIFICATION REGARDING LOBBYING.
The undersigned representative of Agency hereby certifies, to the best of his or her
knowledge and belief, that:
No federal appropriated funds have been paid or will be paid, by or on behalf of Agency, to
any person for influencing or attempting to influence an officer or employee of any agency,
a member of Congress, an officer or employee of Congress in connection with the awarding
of any federal contract, the making of any federal grant, the making of any federal loan, the
entering into of any cooperative agreement and the extension, continuation, renewal,
amendment, or modification of any federal contract, grant, loan or cooperative agreement.
If any funds other than federally appropriated funds have been paid or will be paid to any
person for influencing or attempting to influence an officer or employee of any agency,
member of Congress in connection with this federal contract, grant, loan or cooperative
agreement, Agency shall complete and submit Standard Form-LLL, "Disclosure Form to
Report Lobbying," in accordance with its instructions.
This certification is a material representation of fact upon which reliance was placed when
this Contract was made or entered into. Submission of this certificate is a prerequisite for
making or entering into this Contract imposed by 31 U.S.C. Section 1352. Any person who
fails to file the required certification shall be subject to a civil penalty of not less than
$10,000.00 and not more than $100,000.00 for each such failure.
Agency shall require that the language of this certification be included in all subcontracts or
agreements involving the expenditure of federal funds.
19. LITIGATION AND CLAIMS.
Agency shall give City immediate notice in writing of any action, including any proceeding
before an administrative agency, filed against Agency in conjunction with this Contract or the
Program. Agency shall furnish immediately to City copies of all pertinent papers received by
Agency with respect to such action or claim. Agency shall provide a notice to City within 10 days
upon filing under any bankruptcy or financial insolvency provision of law.
20. NOTICE
All notices required or permitted by this Contract must be in writing and are deemed delivered
on the earlier date of the date actually received or the third day following deposit in a United States
Postal Service post office or receptacle; with proper postage, certified mail return receipt requested;
HOPWA PSA CONTRACT 2023-2024 Page 31
Tarrant County Samaritan Housing, INC
Rev. 10-3-2023
and addressed to the other Party at the address set out below or at such other address as the receiving
Party designates by proper notice to the sending Party.
C
City Attorney's Office
200 Texas Street
Fort Worth, TX 76102
Telephone: 817-3 92-7600
Copy to:
Director of Neighborhood Services Department
200 Texas Street
Fort Worth, TX 76102
Attention: Victor Turner
Telephone: 817-3 92-7540
Copy to:
Neighborhood Services Department
200 Texas Street
Fort Worth, TX 76102
Attention: Julie Pena, Contract Administrator
Telephone: 817-392-7538
Agency:
Tarrant County Samaritan Housing, INC
Kim Robinson
Address: 929 Hemphill St.
Fort Worth, TX 76104
Telephone: 817-509-1697
21. AGENCY HAS LEGAL AUTHORITY TO ENTER INTO CONTRACT.
Agency represents that it possesses the legal authority, pursuant to any proper, appropriate
and official motion, resolution or action passed or taken, to enter into this Contract and to perform
the responsibilities herein required.
22. COUNTERPARTS.
This Contract may be executed in multiple counterparts, each of which shall be considered
an original, but all of which shall constitute one instrument which may be sufficiently evidenced by
one counterpart.
23. PROGRAM INCOME
Parties agree that no program income as defined by HUD shall be earned as a result of this
contract.
HOPWA PSA CONTRACT 2023-2024 Page 32
Tarrant County Samaritan Housing, INC
Rev. 10-3-2023
24. PROHIBITION ON CONTRACTING WITH COMPANIES THAT BOYCOTT
ISRAEL
If Agency has less than ten employees, this contract is for less than $100,000, or Agency
does not meet the definition of a "company" under the applicable section of the Texas Government
Code, this provision shall not apply. Agency acknowledges that in accordance with Chapter 2270 of
the Texas Government Code, the City is prohibited from entering into a contract with a company for
goods or services unless the contract contains a written verification from the company that it: (1)
does not boycott Israel; and (2) will not boycott Israel during the term of the contract. The terms
"boycott Israel" and "company" shall have the meanings ascribed to those terms in Section 808.001
of the Texas Government Code. By signing this contract, Agency certifies that Agency's signature
provides written verification to the City that Agency: (1) does not boycott Israel; and (2) will not
boycott Israel during the term of the contract.
25. PROHIBITION ON BOYCOTTING ENERGY COMPANIES
Agency acknowledges that in accordance with Chapter 2274 of the Texas Government Code,
as added by Acts 2021, 87th Leg., R.S., S.B. 13, § 2, the City is prohibited from entering into a
contract for goods or services that has a value of $100,000 or more that is to be paid wholly or partly
from public funds of the City with a company with 10 or more full-time employees unless the
contract contains a written verification from the company that it: (1) does not boycott energy
companies; and (2) will not boycott energy companies during the term of the contract. The terms
"boycott energy company" and "company" have the meaning ascribed to those terms by Chapter
2274 of the Texas Government Code, as added by Acts 2021, 87th Leg., R.S., S.B. 13, § 2. To the
extent that Chapter 2274 of the Government Code is applicable to this Agreement, by signing this
Agreement, Agency certifies that Agency's signature provides written verification to the City that
Agency: (1) does not boycott energy companies; and (2) will not boycott energy companies during
the term of this Agreement.
26. PROHIBITION ON DISCRIMINATION AGAINST FIREARM AND
AMMUNITION INDUSTRIES
Agency acknowledges that except as otherwise provided by Chapter 2274 of the Texas
Government Code, as added by Acts 2021, 87th Leg., R.S., S.B. 19, § 1, the City is prohibited from
entering into a contract for goods or services that has a value of $100,000 or more that is to be paid
wholly or partly from public funds of the City with a company with 10 or more full-time employees
unless the contract contains a written verification from the company that it: (1) does not have a
practice, policy, guidance, or directive that discriminates against a firearm entity or firearm trade
association; and (2) will not discriminate during the term of the contract against a firearm entity or
firearm trade association. The terms "discriminate," "firearm entity" and "firearm trade association"
have the meaning ascribed to those terms by Chapter 2274 of the Texas Government Code, as added
by Acts 2021, 87th Leg., R.S., S.B. 19, § 1. To the extent that Chapter 2274 of the Government
Code is applicable to this Agreement, by signing this Agreement, Agency certifies that Agency's
signature provides written verification to the City that Agency: (1) does not have a practice, policy,
HOPWA PSA CONTRACT 2023-2024 Page 33
Tarrant County Samaritan Housing, INC
Rev. 10-3-2023
guidance, or directive that discriminates against a firearm entity or firearm trade association; and (2)
will not discriminate against a firearm entity or firearm trade association during the term of this
Agreement.
[SIGNATURES APPEAR ON NEXT PAGE]
HOPWA PSA CONTRACT 2023-2024 Page 34
Tarrant County Samaritan Housing, INC
Rev. 10-3-2023
IN WITNESS WHEREOF, the Parties hereto have executed 4 duplicate originals of this
Contract in Fort Worth, Tarrant County, Texas.
ATTEST: � a
L°°nnEosg4`o
Jannette Goodall, City Secretary
M&C: 23-0631
Date: August 8, 2023
1295 Certification No. 2023-994136
RECOMMENDED BY:
CITY OF FORT WORTH
By:
Fernando Costa, Assistant City Manager
Victor Turner
Director of Neighborhood Services Department
APPROVED AS TO FORM AND LEGALITY:
u/
Jessika Williams, Assistant City Attorney
CONTRACT COMPLIANCE ADMINISTRATOR:
By signing, I acknowledge that I am the person responsible
for the monitoring and administration of this contract, including
ensuring all performance and reporting requirements
Julie Pena
Julie Pena (Oct 16. 202312,45 CDT)
Name: Julie Pena, MSW
Title: Sr. Human Services Specialist
TARRANT COUNTY SAMARITAN HOUSING, INC:
K Po6� OFFICIAL RECORD
By: CITY SECRETARY
Kim Robinson, Chief Executive Officer FT. WORTH, Tx
HOPWA PSA CONTRACT 2023-2024 Page 35
Tarrant County Samaritan Housing, INC
Rev. 10-3-2023
EXHIBITS:
EXHIBIT "A" — Program Summary
EXHIBIT "A-1" — 2023 HUD Income Limits
EXHIBIT "A-2" - Requirements for Completion of "Getting to Work Training Curriculum"
EXHIBIT `B" — Budget
EXHIBIT "C" — Audit Certification Form
EXHIBIT
"D"
— Reimbursement Forms
EXHIBIT
"E"
— Form of Income Self -Certification
EXHIBIT
"F"
— Standards for Complete Documentation
EXHIBIT
"G"
— Section 3 Reporting Forms (NOT APPLICABLE)
EXHIBIT
"H"
— Overview Report
EXHIBIT
"I" —
MBE Reporting Form
EXHIBIT
"J" —
Duties of the Parties for Use of NSD Community Centers
EXHIBIT "K" — Notice of Beneficiary Rights
EXHIBIT "L" — Notice of Occupancy Rights Under VAWA
EXHIBIT "M" —VAWA Emergency Transfer Request Form
HOPWA PSA CONTRACT 2023-2024 Page 36
Tarrant County Samaritan Housing, INC
Rev. 10-3-2023
Tarrant County Samaritan Housing, Inc. EXHIBIT "A"
HOPWA PROGRAM SUMMARY
PROGRAM SUMMARY
(HOPWA)
October 1, 2023 to September 30, 2024 $1,300,000.00
PERIOD AMOUNT
Capitalized terms not defined herein shall have meanings assigned them in the Contract.
PROGRAM:
The Program provides supportive services and Tenant Based Rental Assistance (TBRA) to
HOPWA-Eligible Clients living in the Samaritan Villages Apartments, the Samaritan House
Single Room Occupancy ("SRO") Facility, and in scattered -site rental -voucher supported housing.
The supportive services include case management and housing counseling. Program services may
also include congregate meals; substance abuse counseling; medical transportation; recreational
and social programs; educational programs; and life and job skills programs.
TBRA includes long-term monthly rental assistance. Clients must be Income Eligible according
to HUD guidelines, live in a rental unit that passes habitability inspections, and have an identified
housing need as determined by the client's case manager.
HOPWA Funds will pay for direct assistance for TBRA clients. HOPWA Funds will be used to
pay for a percentage of supportive service salaries and fringe benefits, associated with the Program.
HOPWA Funds will also be used to pay for the operational expenses of the Agency's SRO Facility
located at 929 Hemphill Street, Fort Worth, TX 76104. Operational expenses consist of salaries
and fringe benefits for property management and maintenance staff.
No more than 7% of the HOPWA Funds will be used to pay for administrative costs, including
salaries and fringe benefits and City -required insurance associated with the Program.
Agency's office and Program services will be available at 929 Hemphill Street, Fort Worth, Texas
76104, Monday through Friday, 9:00 a.m. to 5:00 p.m. Program services may also be provided at
clients' homes. The SRO is staffed 24 hours a day, 7 days a week.
The Program will provide services to HOPWA-Eligible clients residing in Tarrant, Johnson,
Parker, and Wise counties.
REGULATORY CLASSIFICATION:
IDIS matric Code(s) and Service Category: 3 1 C HOPWA Project Sponsor Activity
3 1 D HOPWA Project Sponsor Administration
HOPWA 2023-2024 — EXHIBIT "A" — PROGRAM SUMMARY
Page 1
OA PROG AM G LS:
Minimum Number of Fort Worth Clients to be Served: The Program must provide Supportive
Services to a minimum of 114 Unduplicated Clients. Unduplicated Clients must be residents of
Tarrant, Johnson, Parker, and Wise counties as shown by the monthly reports on Attachment
III. The Program will also provide Facility Based Housing Subsidy Assistance through the
housing operations to 60 household housing units and TBRA services to a minimum of 30
households. 24 households will receive Supportive Services only.
HOPWA 2023-2024 — EXHIBIT "A" — PROGRAM SUMMARY
Page 2
2023 HOPWA Income limits
AMI 1 person
2 people
3 people
4 people
5 people 6
people
7 people 8 people
30% $20,100
$23,000
$25,850
$28,700
$31,000
$33,300
$35,600 $37,900
50% $33,500
$38,300
$43,100
$47,850
$51,700
$55,550
$59,350 $63,200
80% $53,600
$61,250
$68,900
$76,550
$82,700
$88,800
$94,950 $101,050
Effective 611512023
EXHIBIT "A-2"
REQUIREMENTS FOR COMPLETION OF "GETTING TO WORK TRAINING
CURRICULUM"
HOPWA PSA CONTRACT 2023-24 Page 1
EXHIBIT "A-2" REQUIREMENTS FOR COMPLETION OF "GETTING TO WORK TRAINING CURRICULUM"
Getting to Work:
A Training Curriculum for HIV/AIDS Service Providers and Housing Providers
At least 1 Agency employee must complete this required training curriculum by the deadline of April
15, 2023. Proof of completion must be submitted with the April reimbursement request.
The Getting to Work Training Curriculum is divided into 3 online modules:
Module 1: Understanding the Value of Work
Module 2: Adopting an Employment and Training Mindset — Organizationally and Individually
Module 3: Incorporating Employment into the HIV/AIDS Service Menu
To view the modules:
1. Click the module title.
2. You will be prompted to either create or log into your HUD Exchange Learn account.
3. Follow this guidance when creating a HUD Exchange account:
Step 1 of 2 screen: Fill out the required Personal Information, and Login Information sections.
For the Organization Information, if you are not affiliated with a HUD program, choose None
of the Above and I am an Individual.
Step 2 of 2 screen: All HUD Program Experience fields on the Learner Profile page are
optional. Click Update to complete the account creation process.
4. After creating an account or logging in, you will enter the HUD Exchange Learn system.
5. Click the Enroll button on the HUD Exchange Learn course description to access the course.
6. The module name will appear under Activities. Click the Module Name to access the course.
7. The module will launch in a new window, so please make sure your pop-up blockers are
turned off.
To receive credit for completing each module:
1. Take the completion quiz under Activities on the HUD Exchange Learn course description.
Each module has a quiz.
2. Score 80% or better on the quiz. You may take the quiz multiple times.
3. After you pass the quiz, you will be able to print a completion certificate on the HUD
Exchange Learn course description.
You can access information about the modules by visiting the HUD Exchange website at
www.hudexchanae.com or by using the following link: https://www.hudexchanae.info/trainina-
events/dol-hud-.ettinb-to-work-curriculum-for-hiv-aids-providers. You may also contact your
assigned contract administrator to get additional information.
HOPWA PSA CONTRACT 2022-2023 Page 2
EXHIBIT "A-2" REQUIREMENTS FOR COMPLETION OF "GETTING TO WORK TRAINING CURRICULUM"
Tarrant County Samaritan Housing, INC
EXHIBIT "B" - BUDGET
Account I
Grant Budget
A I B
C
D
Total
ADMINISTRATIVE
PERSONNEL
Salaries
1001
$ 40,716.00
$
417,402.00
$
458,118.00
FICA
1002
$ 3,115.00
$
31,931.00
$
35,046.00
Life/Disability Insurance
1003
$ 33.00
$
360.00
$
393.00
Heahh/Dentallnsurance
1004
$ 1,960.00
$
27,272.00
$
29,232.00
Unemployment -State
1005
$
4,581.00
$
4,581.00
Worker's Compensation
1006
$
9,162.00
$
9,162.00
Contract Labor -Accounting
1007
$
-
Mileage
1008
$
-
Insurance -Commercial Umbrella
Liability
1009
$
32,000.00
$
32,000.00
Insurance -Directors and
Officers
1010
$
-
Insurance -Fidelity Bond or
Equivalent
1011
$ 500.00
$
-
$
500.00
Retirement
$ 711.00
$
6,403.00
$
7,114.00
HMIS Fees
$ 1,200.00
$
-
$
1,200.00
Other Admin
$ 18,275.00 $ 34,121.00 $
30,915.13 $
46,588.87
$
129,900.00
TOTAL ADMINISTRATIVE
EXPENSES
$ 48,235.00
$ 18,275.00 $ 34,121.00 $
30,915.13 $
575,699.87
$
707,246.00
% Administrative Cost
4%
SUPPORTIVE SERVICES
PROGRAM PERSONNEL
Salaries
2001
$
586,847.00
$ 46,388.00
$ 89,584.00
$
88,046.00
$ 71,387.00
$
882,252.00
FICA
2002
$
43,979.00
$ 3,549.00
$ 6,847.00
$
550.00
$ 12,567.00
$
67,492.00
Life/Disability Insurance
2003
$
1,126.00
$ 83.00
$ 248.00
$
47.00
$ 117.00
$
1,621.00
Heahh/DentalInsurance
2004
$
85,813.00
$ 8,911.00
$ 14,139.00
$
4,644.00
$ 21,808.00
$
135,315.00
Unemployment -State
2005
$
-
$ 321.00
$ 8,502.00
$
8,823.00
Worker's Compensation
2006
$
-
$ 821.00
$ 16,824.00
$
17,645.00
Retirement
$
4,307.00
$
1,222.00
$ 3,077.00
$
8,606.00
SUPPLIES AND SERVICES
Office/Medical Supplies
3001
Office Equipment Rental
3002
Postage
3003
Printing
3004
MISCELLANEOUS
oppr
Contract Labor -Nutritionist
4001
$ 6,000.00
$ 6,000.00
$ 12,000.00
Food Supplies
4002
$ -
Other Supportive Services
$ 100,873.00
$ 3,365.00
$ 17,472.00
$ 38,584.00
$ 160,294.00
FACILITY AND UTILITIES
Telephone
5001 $
Electric
5002 $
Gas
5003 $
Water and Wastewater
5004 $
Solid Waste Disposal
5005 $
Rent (City needs copy of lease
before expenses can be
reimbursed)
5006
Custodial Services
5007 $
Maintenance/Repairs
5008 $
Building Security
5009 $
HOPWA PSA CONTRACT 2023-2024 - EXHIBIT "B" - BUDGET
Page 1
INSURANCE
Auto 6001
TOTAL SUPPORTIVE
SERVICE EXPENSES $ 722,072.00 $ 159,804.00 $ 115,325.00 $ 117,981.00 $ 178,866.00 $ 1,294,048.00
DIRECT ASSISTANCE-STRMU
Short-term Rent Assistance 7001
Short-term Mortgage Assistance 7002
Short-term Utilities Assistance 7003
Total Direct Assistance-STRMU
DIRECT ASSISTANCE-TBRA
(TBRA) 8001 $ 300,478.00 $ 4,680.00 $ 370,649.00 $ 29,610.00 $ $ 705:417.00
Total Direct Assistance-TBRA $ 300,478.00 $ 4,680.00 $ 370,649.00 $ 29,610.00 $ - $ 705417.00
FACILITY BASED OPERATIONS
PERSONNEL
I i
I
I
I I I
'
Salaries
9001
$
169,722.00
$
84,453.00
$
254,175.00
FICA
9002
$
12,984.00
$
6,460.00
$
19,444.00
Life/Disability Insurance
9003
$
340.00
$
152.00
$
492.00
Health/DentalInsurance
9004
$
23,934.00
$
8,140.00
$
32,074.00
Unemployment -State
9005
$
-
$
2,542.00
$
2,542.00
Worker's Compensation
9006
$
-
$
5,084.00
$
5,084.00
Retirement
$
2,435.00
$
1,648.00
$
4,083.00
Contract Labor - Custodial
$
19,800.00
$
-
$
19,800.00
Insurance -Commercial Property
and Professional Liability
9007
$
-
TOTAL FACILITY BASED
OPERATION EXPENSES
$
229,215.00
$ - $ - $ - $
108,479.00
$
337,694.00
BUDGET TOTAL
$
1,300,000.00
$ 182,759.00 $ 520,095.00 $ 178,506.13 $
863,044.87
$
3,044,405.00
FUNDING A:
FUNDING B:
FUNDING C:
FUNDING D:
Ryan White Part A, State Services
HUD CoC - Grace Village, HUD Coc TBLA15, HUD CoC - Youth Homeless
Tarrant County HOPWA
Fund Development
HOPWA PSA CONTRACT 2023-2024 - EXHIBIT "B" - BUDGET
Page 2
The following tables were created for the purpose of preparing, negotiating, and determining the cost
reasonableness and cost allocation method used by the Agency for the line item budget represented on
the first page of this EXHIBIT `B" — Budget. The information reflected in the tables is to be
considered part of the terms and conditions of the Contract. Agency must have prior written approval
by the City to make changes to any line item in the Budget as outlined in Section 5.2.2 in the
Contract. The deadline to make changes to EXHIBIT "B" — Budget is.
SALARY DETAIL - ADMINISTRATIVE
Est. Percent to
Amount to
Position Title
Annual Salary
Grant
Grant
Accounting Assistant
$
40,000.00
10%
$
4,000.00
Accounting Manager
$
75,448.00
10%
$
7,545.00
President and CEO
$
161,710.00
10%
$
16,171.00
Vice President of Finance
$
130,000.00
10%
$
13,000.00
Development Manager
$
50,960.00
$
-
TOTAL
$
458,118.00
$
40,716.00
FRINGE DETAIL - ADMINISTRATIVE
Percent of
Est. Percent to
Amount to
Payroll
Amount
Grant
Grant
FICA
7.65% $
35,046.00
8.9%
$
3,115.00
Life/Disability Insurance
$
393.00
8.4%
$
33.00
Health/DentalInsurance
$
29,232.00
6.7%
$
1,960.00
Unemployment -State
$
4,581.00
$
-
Worker's Compensation
$
9,162.00
$
-
Retirement
$
7,114.00
10.0%
$
711.00
TOTAL
$
85,528.00
6.8%
$
5,819.00
MISCELLANEOUS - ADMINISTRATIVE
Est. Percent to
Amount to
Total Budget
Grant
Grant
Contract Labor -Accounting
$
-
$
-
Mileage
$
-
$
-
Insurance -Commercial Umbrella Liability
$
32,000.00
$
-
Insurance -Directors and Officers
$
-
$
-
Insurance -Fidelity Bond or Equivalent
$
500.00
100.0%
$
500.00
HMIS Fees
$
1,200.00
100.0%
$
1,200.00
Other Admin
$
129,900.00
$
-
TOTAL
$
163,600.00
1.0%
$
1,700.00
SALARY DETAIL - SUPPORTIVE SERVICES
Est. Percent to Amount to
Position Title Annual Salary I Grant Grant
HOPWA PSA CONTRACT 2019-2020 - EXHIBIT "B" - BUDGET
AIDS Outreach Center, Inc. Page 4
Case Manager 1
Case Manager 2
Case Manager 3
Cook 1
Cook 2
Cook 3
Food Service Manager
Head Cook
Housing Manager
Intake Coordinator
LCDC Case Manager
Life Skills Enrichment Coordinator
Life Skills Enrichment Specialist
Life Skills Enrichment Specialist
Life Skills Enrichment Specialist
Life Skills Enrichment Specialist
Life Skills Enrichment Specialist
Life Skills Enrichment Specialist
Life Skills Enrichment Specialist
Life Skills Enrichment Specialist
Life Skills Enrichment Specialist
Patient Navigator/Case Worker
Resident Services Coordinator
Resident Services Coordinator
Resident Services Manager
Vice President of Programs
TOTAL
$ 45,320.00
50.0%
$
22,660.00
$ 43,260.00
35.0%
$
15,141.00
$ 45,000.00
50.0%
$
22,500.00
$ 28,922.00
75.0%
$
21,692.00
$ 15,600.00
100.0%
$
15,600.00
$ 26,030.00
75.0%
$
19,523.00
$ 55,000.00
75.0%
$
41,250.00
$ 31,815.00
75.0%
$
23,861.00
$ 57,680.00
75.0%
$
43,260.00
$ 39,253.00
100.0%
$
39,253.00
$ 48,410.00
50.0%
$
24,205.00
$ 34,707.00
100.0%
$
34,707.00
$ 28,922.00
100.0%
$
28,922.00
$ 1,500.00
100.0%
$
1,500.00
$ 19,282.00
100.0%
$
19,282.00
$ 28,922.00
100.0%
$
28,922.00
$ 28,922.00
100.0%
$
28,922.00
$ 1,545.00
100.0%
$
1,545.00
$ 1,545.00
100.0%
$
1,545.00
$ 1,545.00
100.0%
$
1,545.00
$ 19,282.00
100.0%
$
19,282.00
$ 38,606.00
40.0%
$
15,443.00
$ 38,480.00
$
-
$ 41,200.00
50.0%
$
20,600.00
$ 59,740.00
75.0%
$
44,805.00
$ 101,764.00
50.0%
$
50,882.00
$ 882,252.00 66.5% $ 586,847.00
FRINGE DETAIL - SUPPORTIVE SERVICES
Percent of
Est. Percent to
Amount to
Payroll
Amount
Grant
Grant
FICA
7.65% $
67,492.00
65.2%
$
43,979.00
Life/Disability Insurance
$
1,621.00
69.5%
$
1,126.00
Health/DentalInsurance
$
135,315.00
63.4%
$
85,813.00
Unemployment -State
$
8,823.00
$
-
Worker's Compensation
$
17,645.00
$
-
Retirement
$
8,606.00
50.0%
$
4,307.00
TOTAL
$
239,502.00
56.5%
$
135,225.00
SUPPLIES AND SERVICES - SUPPORTIVE SERVICES
Est. Percent to Amount to
Total Budget Grant Grant
Office/Medical Supplies
HOPWA PSA CONTRACT 2019-2020 - EXHIBIT "B" - BUDGET
AIDS Outreach Center, Inc. Page 5
Office Equipment Rental
Postage
Printing
TOTAL $
MISCELLANEOUS - SUPPORTIVE SERVICES
Est. Percent to Amount to
Total Budget Grant Grant
Contract Labor -Nutritionist $ 12,000.00 $ -
Food Supplies
Other Supportive Services $ 160,294.00 $ -
TOTAL $ 172,294.00 $ -
FACILITY AND UTILITIES - SUPPORTIVE SERVICES
Est. Percent to Amount to
Total Budget Grant Grant
Utilities (Electric, Gas, water, etc)
Electric
Gas
Water and Wastewater
Solid Waste Disposal
Rent (City needs copy of lease before
expenses can be reimbursed)
Custodial Services
Maintenance/Repairs
Building Security
TOTAL
HOPWA PSA CONTRACT 2019-2020 - EXHIBIT "B" - BUDGET
AIDS Outreach Center, Inc. Page 6
LEGAL, FINANCIAL AND INSURANCE - SUPPORTIVE SERVICES
Est. Percent to Amount to
Total Budget Grant Grant
Professional Liability/Business Auto
TOTAL
DIRECT ASSISTANCE - STRMU
Est. Percent to
Amount to
Total Budget
Grant
Grant
Short -Term Rent Assistance
-
Short Term Mortgage Assistance
-
Short Term Utilities Assistance
-
TOTAL
$
-
$
-
DIRECT ASSISTANCE - TBRA
Est. Percent to
Amount to
Total Budget
Grant
Grant
Tenant Based Rental Assistance
$
705,417.00
42.6%
$
300,478.00
TOTAL
$
705,417.00
42.6%
$
300,478.00
SALARY DETAIL - FACILITY BASED OPERATIONS
Est. Percent to
Amount to
Position Title
Annual Salary
Grant
Grant
Facility Manager
$
55,000.00
75.0%
$
41,250.00
Leasing Manager
$
59,740.00
40.0%
$
23,896.00
Lead Maintenance Technician
$
40,684.00
75.0%
$
30,513.00
Maintenance Technician
$
35,671.00
75.0%
$
26,753.00
Maintenance Assistant
$
28,080.00
75.0%
$
21,060.00
Office Assistant
$
35,000.00
75.0%
$
26,250.00
TOTAL
$
254,175.00
66.8%
$
169,722.00
FRINGE DETAIL - FACILITY
BASED OPERATIONS
Percent of
Est. Percent to
Amount to
Payroll
Amount
Grant
Grant
FICA
7.65% $
19,444.00
66.8%
$
12,984.00
Life/Disability Insurance
$
492.00
69.1 %
$
340.00
Health/DentalInsurance
$
32,074.00
74.6%
$
23,934.00
Unemployment -State
$
2,542.00
$
-
Worker's Compensation
$
5,084.00
$
-
Retirement
$
4,083.00
59.6%
$
2,435.00
TOTAL
$
63,719.00
62.3%
$
39,693.00
HOPWA PSA CONTRACT 2019-2020 - EXHIBIT "B" - BUDGET
AIDS Outreach Center, Inc. Page 7
MISCELLANEOUS - FACILITY BASED OPERATIONS
Est. Percent to
Total Budget Grant
Insurance -Commercial Property and
Professional Liability
Contract Labor - Custodial $ 19,800.00
TOTAL $ 19,800.00
100.0% $
Amount to
Grant
19,800.00
19,800.00
HOPWA PSA CONTRACT 2019-2020 - EXHIBIT "B" - BUDGET
AIDS Outreach Center, Inc.
Page 8
DocuSign Envelope ID: AD852CO7-333C-4738-AD75-OF6BO8CO9FB7
EXHIBIT "C"
AUDIT CERTIFICATION FORM
HOWA PSA CONTRACT — EXHIBIT "C"
AUDIT CERTIFICATION FORM --
DocuSign Envelope ID: AD852CO7-333C-4738-AD75-OF6BO8CO9FB7
AUDIT CERTIFICATION FORM AND AUDIT REQUIREMENTS
Agency:Tarrant County Samaritan Housing Inc.
Fiscal Year Ending: September 30, 2024
❑� During the fiscal year in which funds will be received, we will exceed the federal expenditure
threshold of $750,000. We will have our Single Audit or Program Specific Audit completed
and will submit the audit report described in 2 CFR Part 200 within 7 months after the end
of the audited fiscal year or 30 days within its completion, whichever is the earlier date.
During the fiscal year in which funds will be received, we will not exceed the $750,000
federal expenditure threshold required for a Single Audit or a Program Specific Audit to be
performed this fiscal year. (Fill out schedule below)
Federal Expenditure Disclosure
MUST be filled out if Single Audit or Program Audit is NOT required.
Pass Through Program Name & Contract
Federal Grantor Grantor CFDA Number Number Expenditures
DOCUSigned by:
°�trm. t�I.NA9�A.
F236og"Sitffatory and Title
Total Federal Expenditures for this Fiscal Year:
9/28/2023
Date
Failure to submit this or a similar statement or failure to submit a completed single audit package
as described in the federally required audit requirements described in 2 CFR Part 200, as
applicable, by the required due date may result in suspension of funding and may affect eligibility
for future funding. Notwithstanding the above, this certification acknowledges the agency's
commitment to meet all other financial reporting, financial statements, and other audit
requirements as may be set forth in the Contract.
HOPWA PSA CONTRACT — EXHIBIT "C" — AUDIT CERTIFICATION FORM 2
Agency:
Program:
ATTACHMENT II
City of Fort Worth
Neighborhood Services Depart
Expenditure Worksheet
Please gr
Line
71
No.
Check No.
Date
Payee
Description/Job Title*
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
Total
*For Salaries, state employee's title under Description/Job Title. Rent must identify tenant
;ment
•oup like account codes.
Account Code
(See Key to
Right) Amount
Only highlighted codes can be reimbursed
Expense Line Item
Ad& Account
ADMINISTRATIVE
Salaries
1001
FICA
1002
Life/Disability Insurance
1003
Health/Dental Insurance
1004
Unemployment -State
1005
Worker's Compensation
1006
Office Supplies
1007
Food Supplies
1008
Insurance
1009
Accounting
1010
Contract Labor
1011
Other()
1012
SUPPORTIVE SERVICES
PROGRAM PERSONNEL
Salaries
2001
FICA
2002
Life/Disability Insurance
2003
Health/Dental Insurance
2004
Unemployment -State
2005
Worker's Compensation
2006
SUPPLIES AND SERVICES
Office/Medical Supplies
3001
Office Equipment Rental
3002
Postage
3003
Printing
3004
MISCELLANEOUS
Contract Labor -Nutritionist
4001
Food Supplies
4002
FACILITIES AND UTILITIES
Telephone
5001
Electric
5002
Gas
5003
Water and Wasterwater
5004
Solid Waste Disposal
5005
Rent (copy of lease to operate business out
of before expenses can be reimbursed)
5006
Custodial Services
5007
Mainenance/Repairs
5008
(Building Security
5009
LEGAL, FINANCIAL AND INSURANCE
Professional Liability/Business Auto
6001
DIRECT ASSISTANCE-STRMU
Short-term Rent Assistance
7001
Short-term Mortgage Assistance
7002
Short-term Utilities Assistance
7003
DIRECT ASSISTANCE-TBRA
Tenant Based Rental Assistance (TBRA)
8001
FACILITIES BASED OPERATIONS
PROGRAM PERSONNEL
Salaries
9001
FICA
9002
Life/Disability Insurance
9003
Health/Dental Insurance
9004
Unemployment -State
9005
lWorker's Compensation
9006
Insurance -Commercial Property and
Professional Liability
9007
EXHIBIT "E"
INCOME CERTIFICATION FORMS
HOPWA PSA Contract 2023-2024 Page 1
City of Fort Worth
CERTIFICATION OF INCOME STATEMENT
Applicant Name:
Current Address:
City and Zip:
Last Name
First Name
Phone #:
Household Members and Income
(including applicant)
TOTAL NUMBER OF FAMILY MEMBERS
Total Gross Annual Household Income:
Age Monthly Source of Income
Income $$
(Include Yourself, Spouse, Children, etc.)
PERSONAL INFORMATION: (Check one in each item. This Information is Required for Federal Reporting Purposes)
a. ❑MALE
❑FEMALE
❑GENDER NONBINARY
❑TRANSGENDER FEMALE
❑TRANSGENDER MALE
❑GENDER NOT DISCLOSED
b. ❑WHITE ❑BLACK/AFRICAN AMERICAN
❑BLACK/AFRICAN AMERICAN & WHITE ❑AMERICAN INDIAN/ALASKAN NATIVE
❑ASIAN ❑AMERICAN INDIA/ALASKAN NATIVE & WHITE
❑ASIAN & WHITE ❑NATIVE HAWAIIAN/OTHER PACIFIC ISLANDER
❑AMERICAN INDIAN/ALASKAN NATIVE & BLACK/AFRICAN AMERICAN
❑MULTI-RACIAL/OTHER
c. ETHNICITY d. DISABLED e. IS HEAD OF HOUSEHOLD FEMALE?
❑ HISPANIC ❑ YES ❑ YES
❑ NON -HISPANIC ❑ NO ❑ NO
Certification: I certify that the information I am providing is true and could be subject to verification at any
time by a third party. I also acknowledge that the provision of false information could leave me subject to the
penalties of Federal, State and local law.
Signature of Applicant Date
WARNING: TITLE 18, SECTION 1001 OF THE U.S. CODE STATES THAT A PERSON IS GUILTY OF A FELONY
FOR KNOWINGLY AND WILLINGLY MAKING FALSE OR FRAUDULENT STATEMENTS TO ANY DEPARTMENT OF
THE UNITED STATES GOVERNMENT.
Household Size:
Applicable Income Limit:
For use by Agency staff only ------------
Gross Annual Income:
Is Applicant Eligible?
Check if Applicant refused to provide demographic information:
Staff Assessment of Demographics:
HOPWA PSA Contract 2023-2024 Page 2
Person Making Determination:
Date:
NOTE: Address, income amounts and sources for ALL household members are required.
Ciudad de Fort Worth
CERTIFICACION DE DECLARACION DE INGRESOS
Nombre del Solicitante:
Direccion de Actualidad:
Ciudad y Codigo Postal:
Apellido Nombre
Telefono:
Miembros Del Ho2ar e Ingresos
"Incluyendo el/la Solicitante)
Had Ingreso Origen de Ingresos
Mensual
* TOTAL NOMERO DE MIEMBROS DEL HOGAR
Total Anual de Ingresos del hogar:
**INFORMACION PERSONAL: (Seleccione uno en cada articulo.
a. ❑MASCULINO
❑FEMININO
❑GENERO NO BINARIO
❑MUJER TRANSGENERO
❑HOMBRE TRANSGENERO
❑GENERO NO REVELADO
b. ❑ BLANCO
❑NEGRO/AFRICANO AMERICANO & BLANCO
❑ASIATICO
❑ASOATICO & BLANCO
❑MULTIRRACIAL/OTRO
(Inclfiyase Usted.)
Esta informacion es requerida por el Gobierno federal.)
❑NEGRO/AFRICANO AMERICANO
❑INDIO AMERICANO/NATIVO DE ALASKA
❑INDIO AMERICANO/NATIVO DE ALASKA & BLANCO
❑NATIVO HAWAINO/OTRO DE LAS ISLAS PACIICAS
c. ETHNICIDAD d. INCAPACITADO e. DES LA CABEZA DEL HOGAR MUJER?
❑ HISPANO ❑ SI ❑ Si
❑ NO-HISPANO ❑ NO ❑ NO
Certificacion: Yo certifico que la informacion que yo estoy proporcionando es verdadera y puedo ser sujeto a
verificacion a cualquiera hora por tercera parte. Yo tambien reconozco que la provision de informacion falsa
puede dejarme sujeto a penalidades Federales, Estatales, y a ley local.
Firma del Solicitante
Fecha
ADVERTENCIA: TITULO 18, SECCI6N 1001 DEL CODIGO DE LOS ESTADOS UNIDOS INDICA QUE UNA
PERSONA ES CULPABLE DE UN DELITO FOR SABER Y VOLUNTARIAMENTE HACER DECLARACIONES FALSOS O
FRAUDULENTAS A CUALQUIER DEPARTAMENTO DE GOBIERNO DE LOS ESTADOS UNIDOS.
-----------------Para use de empleados de la agencia -----------
HOPWA PSA Contract 2023-2024 Page 3
# De Miembros de Familia: Ingreso Anual:
Limite de Ingreso:
�Es solicitante elegible? :
Compruebe si el solicitante se nego a dar su informacion personal:
Evaluacion del empleado sobre informacion personal:
Persona haciendo la determinacion: Fecha:
Note: La direction de la casa y los ingresos (y sus origenes) para todos los miembros del hogar, es requerida.
HOPWA PSA Contract 2023-2024 Page 4
EXHIBIT "F"
STANDARDS OF DOCUMENTATION
HOPWA PSA CONTRACT -- EXHIBIT "F" -- STANDARDS OF DOCUMENTATION
2023-24 Documentation Standards for
HOPWA Public Service Contract
Employee Salaries and Benefits - City will only reimburse a percentage of any employee's salary and benefits who work directly with the HOPWA-funded Program.
Percentages will be cost allocated and determined prior to the execution of the HOPWA Contract. Agencies requesting the reimbursement of 100% of any Agency
employee will require prior City approval. Agencies must show calculation on how the HOPWA portion of employee salaries and benefits were calculated consistently
with the HOPWA Contract.
If an employee works on both a HOPWA eligible and non-HOPWA eligible program(s), the City will only reimburse for a reasonable
portion of the employee's salary. Prior to the execution of the HOPWA Contract, the Agency will provide the City with a written
statement on how each employee's time will be allocated. If an employee works 100% of their time directly with the HOPWA-funded
Program, then 100% of the employee's salary maybe eligible for reimbursement. Agency must submit a written statement that 100% of
the employee's time is spent working directly with the HOPWA-funded Program. Statements must be signed by a person authorized to
sign on behalf of the Agency and will be submitted with the October invoice.
Salaries X X
Reimbursement requests must include a signed timesheet and work log that reflects the hours worked by the employee(s) working
directly on the HOPWA-funded Program. For employees who are paid with multiple funding sources, timesheets must reflect all funding
sources. If separate timesheets are kept for each funding source, all such timesheets must be submitted to City. Timesheets must be
signed by employee and supervisor. Agency must show a calculation and documentation of how the employee's salary was calculated
and invoiced to City.
*If employees are paid by direct deposit rather than check, then the agency must submit both the direct deposit payment company's
report (such as an ADT report) and a bank statement or check showing payment to the direct deposit company.
FICA/Medicare X X X
Life Insurance x x x
Health x x x
If the City pays gross salary, this is already included. If the City pays the employer portion, the Agency must provide proof that the
Insurance
employee is enrolled in the benefit plan, must show a calculation and documentation of how the invoiced amount was calculated, and
Disability
must provide documentation showing payment. Invoice and proof of payment are only required with the first reimbursement request and
x x x
Insurance
at any time there are changes to amounts, enrollments, disenrollments, etc.
Unemployment x x x
Insurance
If the City pays gross salary, this is already included. If the City pays the employer portion, the Agency must provide proof that the
Retirement x x x
employee is enrolled in the benefit plan, must show a calculation and documentation of how the invoiced amount was calculated, and
must provide documentation showing payment. Invoice and proof of payment are only required with the first reimbursement request and
at any time there are changes to amounts, enrollments, disenrollments, etc.
_
Materials, Equipment, Goods and Supplies - City will only reimburse for the cost allocated percent or amount spent in support of the HOPWA-funded Program.
Agencies requesting reimbursement for these items will require prior City approval. Agencies must show calculation on how the HOPWA portion of these expenses
were calculated consistently with the HOPWA Contract.
Office Supplies X X
X
Office
Equipment X X X X
X
Rental
Postage X X
X
Printing X X
X
Construction &
Building X X X
X This category is only available for the REACH Program and Habitat for Humanity.
Materials
Sport and
Recreation X X
X
Equipment
Cleaning X X
X
Supplies
Teaching Aids X X X
Craft Supplies X X X
Food Supplies X X X This category is only available to the Program provided by Meals on Wheels
Rent, Utilities and Maintenance - City will only pay for a portion of these expenses. The portion of these expenses will be determined by the square footage attributable to
the HOPWA-funded Program and shall be cost -allocated in accordance with the amount of space used for the HOPWA-funded Program. These expenses may only be in
support of the HOPWA-funded Program. The items listed below require prior City approval and the Agency is required to identify any funding source that pays for the
portion of the expenses that is not paid with HOPWA funds. Agencies must show calculation on how the HOPWA portion of these expenses were calculated consistently
with the HOPWA Contract.
Telephone X X
Gas X X
Water/Wastew X X
ater
Electric X X
Solid Waste )( )( I
HOPWA PSA CONTRACT 2023-2024 Exhibit"F" -- STANDARDS FOR COMPLETE DOCUMENTATION
Facility
Maintenance X X X X
and Repairs
Rent X X X
This item requires approval by the City prior to the execution of the HOPWA Contract. Repairs may be categorized as major/
minor rehabilitation projects and must be approved through the full HUD Environmental Review.
City will pay for a portion of the rent for the Program facility so long as its in proportion to the square footage attributable to the
HOPWA-funded program.
Miscellaneous
This item requires prior approval by the City. Prior to the execution of the HOPWA Contract, the Agency must submit a written
statement that lists the contract labor services to be used during the Contract term. Agency will submit a memo related to the
Contract Labor X X X X X
procurement of such services and will forward any information pertaining to the procurement process to City. This requirement applies
to, but is not limited to, services retained for security services, legal, accounting, transportation providers, educational facilitators,
custodial services, etc. Agencies may not use the contract services of any City of Fort Worth Department.
City -required X X
City will only pay for a percentage of the City -required insurance so long as it's in proportion to the square footage attributable to
Insurance
the HOPWA-funded program.
City requires that the agency submit its fee schedule or formula on how the Agency calculates the childcare scholarship amount. The
fee schedule/formula should demonstrate a breakout of income levels, and for each income level the schedule should demonstrate
Childcare X X
which portion of the expense is to be paid by the family and which portion of the expense is to be reimbursed by the City. A fee
Scholarships
schedule/formula must be submitted to the City prior to the first payment. Agency must submit documentation supporting that the client
is income eligible and that the household is being charged in conformance with the fee schedule. If the fee schedule/formula changes at
any time during the contract term, the Agency must immediately notify City on the date the new fee schedule/formula takes into effect.
"$0" Income
Agecies that are required to verify and provide proof of household income to determine eligibility, must require that anyone who is over
Certifications
the age of 18, living in the housohold, submit a $0 Income Certification.
If an audit is required because federal funds exceed $750,000, then the cost should be split evenly by all grant funding sources.
Audit Services X X X X
Agency must show calculation on how the HOPWA portion of the accounting services were calculated. For example, if the HOPWA
grant is 10% of your Agency's budget, then invoice shall not exceed 10% of the overall cost. Agency must show a calculation and
documentation of how the invoiced amount was calculated, and must provide documentation showing payment.
'Proof of payment effective October 1, 2023:
Payments or Expenses must be documented in the following manner:
A) Image of the check AND bank statement showing the check cleared the bank; OR,
B) Image of the cancelled check (ex. At end of bank statement); OR,
C) Payroll Check Stub, "Advice", or Statement AND Bank Statement indicating payroll; OR,
D) For wire or e-transfers: Reciept or statement from payee/vendor OR bank statement.
Revised as of 08-28-2023 TJ
HOPWA PSA CONTRACT 2023-2024 Exhibit "F" -- STANDARDS FOR COMPLETE DOCUMENTATION
EXHIBIT "G"
SECTION 3 REPORTING FORMS
NOT APPLICABLE
HOPWA PSA CONTRACT 2023-24 -- EXHIBIT "G" -- SECTION 3 REPORTING FORMS Page 1
Section 1:
HOPWA Consolidated APR/CAPER Grantee
Workbook
Performance Report Cover
Housing Opportunities for Persons With AIDS (HOPWA) Program
Revised: 02/24/2022
Consolidated APR/CAPER- Grantee Workbook
OMB Number 2506-0133 (Expiration Date: 1213112024)
Overview
The public reporting burden for this collection of information is estimated to average 40.0 hours, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information.
Performance Reports for HOPWA formula grantees and competitive grantees provide HUD with annual information to support program evaluation and measure program beneficiary outcomes related to
maintaining housing stability; preventing homelessness; and improving access to care and support. This collection of information consolidates the information in the APR and CAPER reports and clarifies
reporting requirements, which will allow HUD's Office of HIV/AIDS Housing to better respond to data calls from Congress and make better program decisions based on more relevant grantee annual data.
Reporting is required for all HOPWA grantees pursuant to 42 U.S.C. § 12911; 24 CFR §§ 574.520(a) and (b); 24 CFR § 91.520(f). The information collected regarding grantees, their respective project sponsors, and
the identities of HOPWA program participants will remain confidential pursuant to 42 U.S.C. § 12905(e) and 24 § CFR 574.440.
Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions to reduce this burden, to Colette Pollard, Reports Management Officer, Department of
Housing and Urban Development, 451 7th Street SW, Room 4176, Washington, DC 20410-5000. When providing comments, please refer to OMB Control No. 2506-0133. HUD may not conduct and sponsor, and
a person is not required to respond to, a collection of information unless the collection displays a valid OMB Control Number.
HOPWA formula grantees are required to submit a Performance Report demonstrating coordination with other Consolidated Plan resources. HUD uses the Performance Report data to obtain essential
information on grant activities, project sponsors, housing sites, units and households, and beneficiaries (which includes racial and ethnic data on program participants). The Consolidated Plan Management
Process tool (CPMP) provides an optional tool to integrate the reporting of HOPWA specific activities with other planning and reporting on Consolidated Plan activities.
In addition, grantees must comply with the Federal Funding Accountability and Transparency Act 2006 (Public Law 109-282), which requires grant recipients to provide general information for all entities
(including contractors and sub -contractors) receiving $25,000+ in federal funding.
HOPWA competitive grantees are required to submit a Performance Report for each operating year in which HOPWA grant funds were expended. Information on each competitive grant is to be reported in a
separate Performance Report. Grantees approved for "Other Activities', as detailed in their grant agreement, are requested to report on their unique program accomplishments.
In addition, grantees must comply with the Federal Funding Accountability and Transparency Act 2006 (Public Law 109-282), which requires grant recipients to provide general information for all entities
(including contractors and sub -contractors) receiving $25,000+ in federal funding.
Continued -use Periods. Grantees that used HOPWA funding for new construction, acquisition, or substantial rehabilitation of a building or structure are required to operate the building or structure for HOPWA-
eligible beneficiaries for a ten (10) years period. If no further HOPWA funds are used to support the facility, in place of completing the "CAP DEV" tab in the Performance Report Worksheet, the grantee must
complete an Annual Report of Continued Project Operation throughout the required use periods. This report is found on the "STEWARD" tab of this workbook. The required use period is three (3) years if the
rehabilitation is non -substantial.
Record Keeping. Names and other individual information must be kept confidential, as required by 24 CFR 574.440. However, HUD reserves the right to review the information used to complete this report for
grants management oversight purposes, except for recording any names and other identifying information. In the case that HUD must review client -level data, no client names or identifying information will be
retained or recorded. Information is reported in aggregate to HUD without personal identification. Do not submit client or personal information in data systems to HUD.
HMIS. In connection with the development of the Department's standards for Homeless Management Information Systems (HMIS), universal data elements are being collected for clients of HOPWA-funded
homeless assistance Droiects. These project sponsor records would include: Name, Social Security Number, Date of Birth, Ethnicity and Race, Gender, Veteran Status, Disabling Conditions, Residence Prior to
Program Entry, Zip Code of Last Permanent Address, Housing Status, Program Entry Date, Program Exit Date, Personal Identification Number, and Household Identification Number. These are intended to match
the elements under HMIS. The HOPWA program -level data elements include: Income and Sources, Non -Cash Benefits, HIV/AIDS Status, Services Provided, Housing Status or Destination at the end of the
operating year, Physical Disability, Developmental Disability, Chronic Health Condition, Mental Health, Substance Abuse, Domestic Violence, Medical Assistance, and T-cell Count. Other HOPWA projects sponsors
may also benefit from collecting these data elements. HMIS local data systems must maintain client confidentiality by using a closed system in which medical information and HIV status are only shared with
providers that have a direct involvement in the client's case management, treatment and care, in line with the signed release of information from the client.
Formula Operating Year. HOPWA formula grants are annually awarded for a three-year period of performance with three operating years. The information contained in this Performance Report must represent a
one-year period of HOPWA program operation that coincides with the grantee's program year; this is the operating year. More than one HOPWA formula grant awarded to the same grantee may be used during
an operating year and the Performance Report must capture all formula grant funding used during the operating year. Project sponsor accomplishment information must also coincide with the operating year this
Performance Report covers. Any change to the period of performance requires the approval of HUD by amendment, such as an extension for an additional operating year.
Competitive Operating Year. HOPWA competitive grants are awarded for a three-year period of performance with Performance Reports submitted for each of the three operating years. The information
contained in this Performance Report should reflect the grantees operating year with the beginning date determined at the time the grant agreement is signed. Project sponsor accomplishment information
must coincide with the operating year this Performance Report covers. Any change to the period of performance requires the approval of HUD by amendment, such as an extension for one additional operating
year. A PSH renewal/replacement grant start date would be coordinated with the close out of the existing grant.
Grantees with an approved extension period of less than 6-months must submit the Performance Report for the third year of the grant term at the end of the approved extension period and incorporate data
from the additional months. Grantees with an approved extension period of 6-months or more must turn in a Performance Report at the end of the operating year and submit a separate extension Performance
Report at the end of the extension period.
Filing Requirements. Within 90 days of the completion of each operating year, grantees must submit their completed Performance Report to the CPD Director in the grantee's State or Local HUD Field Office, and
to the HOPWA Program Office: at HOPWA@hud.gov. Electronic submission to HOPWA Program office is preferred. If electronic submission is not possible, please send an email to the HOPWA@hud.gov email
inbox.
Definitions
Achieved Viral Suppression: When the load or volume of HIV virus present in a person's blood is measured at less than 200 copies per milliliter of blood.
Adjustment for Duplication: Enables the calculation of unduplicated output totals by accounting for the total number of households or units that received more than one type of HOPWA assistance in a given
service category such as HOPWA Subsidy Assistance or Supportive Services.
Administrative Costs: Costs for general management, oversight, coordination, evaluation, and reporting. By statute, grantee administrative costs are limited to 3% of the total grant award, to be expended
over the life of the grant. Project sponsor administrative costs are limited to 7% of the portion of the grant amount they receive.
Anti-Retroviral Therapy: The combination of drugs used to treat HIV.
Area Median Income: The Department of Housing and Urban Development (HUD) sets income limits that determine eligibility for assisted housing programs including the HOPWA program. HUD develops
income limits based on Median Family Income estimates and Fair Market Rent area definitions for each metropolitan area, parts of some metropolitan areas, and each non -metropolitan county. AMI values vary
by location and are published at: https://www.huduser.gov/portal/datasets/il.html
�Beneficiary(ies): All members of a household (with or without HIV) who benefitted from HOPWA assistance during the operating year, NOT including the HOPWA eligible individual (see definition).
Chronically Homeless Person: An individual or family who is homeless and lives or resides as an individual or family who a) lives or resides in a place not meant for human habitation, a safe haven, or in an
emergency shelter; b) has been homeless and living or residing in a place not meant for human habitation, a safe haven, or in an emergency shelter continuously for at least one year or on at least four separate
occasions in the last three years; and c) has an adult head of household (or a minor head of household if no adult is present in the household) with a diagnosable substance use disorder, serious mental illness,
developmental disability (as defined in section 102 of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (42 U.S.C. 15002), post -traumatic stress disorder, cognitive impairments resulting
from a brain injury, or chronic physical illness or disability, including the co -occurrence of two or more of those conditions. Additionally, the statutory definition includes as chronically homeless a person who
currently lives or resides in an institutional care facility, including a jail, substance abuse or mental health treatment facility, hospital or other similar facility, and has resided there for fewer than 90 days if such
person met the other criteria for homeless prior to entering that facility. (See 42 U.S.C. 11360(2)) This does not include doubled -up or overcrowding situations.
Disabling Condition: Evidencing a diagnosable substance use disorder, serious mental illness, developmental disability, chronic physical illness, or disability, including the co -occurrence of two or more of these
conditions. In addition, a disabling condition may limit an individual's ability to work or perform one or more activities of daily living. An HIV/AIDS diagnosis is considered a disabling condition.
Facility -Based Housing Assistance: All eligible HOPWA Housing expenditures for or associated with supporting facilities including community residences, SRO dwellings, short-term facilities, project -based rental
units, master leased units, and other housing facilities approved by HUD.
Faith -Based Organization: Religious organizations of three types: (1) congregations; (2) national networks, which include national denominations, their social service arms (for example, Catholic Charities,
Lutheran Social Services), and networks of related organizations (such as YMCA and YWCA); and (3) freestanding religious organizations, which are incorporated separately from congregations and national
networks.
Grassroots Organization: An organization headquartered in the local community where it provides services; has a social services budget of $300,000 or less annually, and six or fewer full-time equivalent
employees. Local affiliates of national organizations are not considered "grassroots."
HOPWA Eligible Individual: The one (1) low-income person with HIV/AIDS who qualifies a household for HOPWA assistance. This person may be considered "Head of Household." When the Performance
Report asks for information on eligible individuals, report on this individual person only. Where there is more than one person with HIV/AIDS in the household, the additional PWH/A(s), would be considered a
beneficiary(s).
HOPWA Housing Information Services: Services dedicated to helping persons living with HIV/AIDS and their families to identify, locate, and acquire housing. This may also include fair housing counseling for
eligible persons who may encounter discrimination based on race, color, religion, sex, age, national origin, familial status, or handicap/disability.
HOPWA Housing Subsidy Assistance Total: The unduplicated number of households receiving housing subsidies (TBRA, STRMU, Permanent Housing Placement services and Master Leasing) and/or residing in
units of facilities dedicated to persons living with HIV/AIDS and their families and supported with HOPWA funds during the operating year.
Household: A single individual or a family composed of two or more persons for which household incomes are used to determine eligibility and for calculation of the resident rent payment. The term is used for
collecting data on changes in income, changes in access to services, receipt of housing information services, and outcomes on achieving housing stability. Live -In Aides (see definition for Live -In Aide) and non -
beneficiaries (e.g., a shared housing arrangement with a roommate) who resided in the unit are not reported in the Performance Report.
Housing Stability: The degree to which the HOPWA project assisted beneficiaries to remain in stable housing during the operating year.
Improved HIV Viral Load: A reduction in the load or volume of HIV present in the HOPWA eligible individual's blood at the end of the reporting period compared to the beginning of the reporting period. Most
PLWHA who are engaged in medical care have routine laboratory tests. The HOPWA eligible individual's latest laboratory report can be used to determine viral load.
In -kind Leveraged Resources: These are additional types of support provided to assist HOPWA beneficiaries such as volunteer services, materials, use of equipment and building space. The actual value of the
support can be the contribution of professional services, based on customary rates for this specialized support, or actual costs contributed from other leveraged resources. In determining a rate for the
contribution of volunteer time and services, use the criteria described in 2 CFR 200. The value of any donated material, equipment, building, or lease should be based on the fair market value at time of
donation. Related documentation can be from recent bills of sales, advertised prices, appraisals, or other information for comparable property similarly situated.
Leveraged Funds: The amount of funds expended during the operating year from non-HOPWA federal, state, local, and private sources by grantees or sponsors in dedicating assistance to this client population.
Leveraged funds or other assistance are used directly in or in support of HOPWA program delivery.
Live -In Aide: A person who resides with the HOPWA Eligible Individual and who meets the following criteria: (1) is essential to the care and well-being of the person; (2) is not obligated for the support of the
person; and (3) would not be living in the unit except to provide the necessary supportive services. See Code of Federal Regulations Title 24 Part 5.403 and the HOPWA Grantee Oversight Resource Guide for
additional reference.
Master Leasing: Applies to a nonprofit or public agency that leases units of housing (scattered -sites or entire buildings) from a landlord and subleases the units to homeless or low-income tenants. By assuming
the tenancy burden, the agency facilitates housing of clients who may not be able to maintain a lease on their own due to poor credit, evictions, or lack of sufficient income.
Medically Assisted Living Facilities: HOPWA facility -based housing that assists residents with most or all activities of daily living, such as meals, bathing, dressing, and toileting. Regular medical care,
supervision, and rehabilitation are also often available.
Nonbinary: A gender other than singularly female or male.
Operating Costs: Applies to facility -based housing only, for facilities that are currently open. Operating costs can include day-to-day housing function and operation costs like utilities, maintenance, equipment,
insurance, security, furnishings, supplies and salary for staff costs directly related to the housing project but not staff costs for delivering services.
Outcome: The degree to which the HOPWA assisted household has been enabled to establish or maintain a stable living environment in housing that is safe, decent, and sanitary, (per the regulations at 24 CFR
574.310(b)) and to reduce the risks of homelessness and improve access to HIV treatment and other health care and support.
Output: The number of units of housing or households that receive HOPWA assistance during the operating year.
Permanent Housing Placement: A supportive housing service that helps establish the household in the housing unit, including but not limited to reasonable costs for security deposits not to exceed two months
of rent costs.
Program Income: Gross income directly generated from the use of HOPWA funds, including repayments. See grant administration requirements on program income at 2 CFR 200.307.
Project -Based Rental Assistance (PBRA): A rental subsidy program that is tied to specific facilities or units owned or controlled by a project sponsor. Assistance is tied directly to the properties and is not
portable or transferable.
Project Sponsor Organizations: Per HOPWA regulations at 24 CFR 574.3, 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.
SAM: All organizations applying for a Federal award must have a valid registration active at sam.gov. SAM (System for Award Management) registration includes maintaining current information and providing a
valid DUNS number.
Short -Term Rent, Mortgage, and Utility (STRMU) Assistance: A time -limited, housing subsidy assistance designed to prevent homelessness and increase housing stability. Grantees may provide assistance for
up to 21 weeks in any 52-week period. The amount of assistance varies per client depending on funds available, tenant need and program guidelines.
Stewardship Units: Units developed with HOPWA, where HOPWA funds were used for acquisition, new construction and rehabilitation that no longer receive operating subsidies from HOPWA. Report
information for the units is subject to the three-year use agreement if rehabilitation is non -substantial and to the ten-year use agreement if rehabilitation is substantial.
Tenant -Based Rental Assistance (TBRA): TBRA is a rental subsidy program similar to the Housing Choice Voucher program that grantees can provide to help low-income households access affordable housing.
The TBRA voucher is not tied to a specific unit, so tenants may move to a different unit without losing their assistance, subject to individual program rules. The subsidy amount is determined in part based on
household income and rental costs associated with the tenant's lease.
iTransgender: Transgender is defined as a person who identifies with, or presents as, a gender that is different from his/her gender assigned at birth
VAWA Internal Emergency Transfers: Per 24 CFR 5.2005e, an emergency transfer under the VAWA protections refers to an emergency relocation of a tenant to another unit where the tenant would not be
categorized as a new applicant; that is, the tenant may reside in the new unit without having to undergo an application process.
VAWA External Emergency Transfers: Per 24 CFR 5.2005e, an emergency transfer under the VAWA protections refers to an emergency relocation of a tenant to another unit where the tenant would be
categorized as a new applicant; that is, the tenant must undergo an application process in order to reside in the new unit.
Veteran: A veteran is someone who has served on active duty in the Armed Forces of the United States. This does not include inactive military reserves or the National Guard unless the person was called up to
active duty.
Instructions
(instructions for Completing the HOPWA Grantee Performance Report Workbook I
What is the HOPWA Grantee Performance Report Workbook?
This workbook provides information at the Grantee Administration level, including grantee contact information,
annual performance report narratives, and stewardship unit information.
This data will be compiled by the HOPWA Formula or Competitive Grantee, as part of providing annual performance reporting to HUD.
Who completes this form?
This workbook will be completed by the HOPWA Formula or Competitive Grantee ONLY.
Reminder: ANY entity that provides DIRECT HOPWA services - including the HOPWA Grantee - must also complete a separate HOPWA Sponsor Performance Report Workbook.
What tabs should be completed for this report?
EVERY GRANTEE USER should complete these tabs:
• GRANTEE
• CONTACT
• Narrative
STEWARD: The Stewardship tab should only be completed if the Grantee is reporting on HOPWA Stewardship
Units.
Grantees that used HOPWA funding for new construction, acquisition, or substantial rehabilitation of a building or structure are required to
operate the building or structure for HOPWA-eligible beneficiaries for a ten (10) years period.
If no further HOPWA funds are used to support the facility, in place of completing the "CAP DEV" tab in the Sponsor Performance Report
workbook, the grantee must complete an Annual Report of Continued Project Operation throughout the required use periods found on the
"STEWARD" tab of this workbook. The required use period is three (3) years if the rehabilitation is non -substantial.
Important Information:
To ensure the integrity of this workbook, please to not DELETE or ALTER any rows, columns, tabs, or the NAME of the report.
This workbook requires the entry of data only where applicable, with no other actions required.
1 Enter text in empty cells next to questions.
2 Enter numbers where the entry reads "0" and the answer is an amount.
The workbook MUST be submitted in this Excel format. The Grantee will be unable to submit it to HUD if it has been converted to any other format, such as a Word or PDF file.
HOPWA Grantee Performance Report Submission Instructions:
HOPWA Annual Performance reporting is collected and submitted at both the Grantee and Project Sponsor levels.
HUD or a HUD contractor will provide HOPWA Grantees annually with an advance set of named Grantee and Project Sponsor files, based on Project Sponsor activity logged in HUD's IDIS
system relative to the Grantee's Accomplishment Year on which it will be reporting.
Grantees complete this high-level Grantee workbook covering: Grantee organizational information, Grantee contact information, a narrative of all activities provided by the Grantee and
its Project Sponsors, and Stewardship Unit information, as applicable.
Project Sponsors (and any Grantee that provides direct HOPWA activities) will complete a separate detailed annual report, called the "Sponsor Performance Report Workbook," with
every Project Sponsor completing a workbook and submitting it to the Grantee.
The Grantee will then:
• Review all Sponsor Performance Report workbooks for accuracy and will request that the Project Sponsor correct any missing or incorrect information.
• Collect all of the Grantee and Project Sponsor workbooks together.
• Submit the collection of all separate workbook files in a single transmission to HOPWAReports@HUD.gov.
• The entire collection of HOPWA workbook files is considered the Grantee's submission of annual performance reporting under its HOPWA grant agreement.
• Grantees shall submit their annual Performance Report Workbook within 90 days of the completion of their operating (or Accomplishment) year.
Once submitted, the Grantee will receive confirmation regarding the submitted files and may be contacted by HUD or a HUD contractor to confirm or correct reported information, as
necessary.
For assistance with this process, please submit a query to HOPWAReports@HUD.gov.
Grantee Identification
Grantee Grant ID Sponsor(s) ID
Grantee Summary
GRANTEE SUMMARY
Complete the chart below to provide more detailed information about the
agencies and organizations responsible for the administration and
implementation of the HOPWA program.
Question ( Responses
For Competitive Grantees Only
For Competitive Grantees only, what is the grant number?
For Competitive Grantees only, which year (1, 2, or 3) of the grant does
this report cover?
Is the Competitive Grantee a nonprofit organization? Yes or No.
Is the Competitive Grantee a grassroots organization? Yes or No.
For Competitive Grantees only, how much was expended on an "Other
Housing Activity" (as approved in the grant agreement)?
For All HOPWA Grantees
l What is the name of the Grantee organization?
l What is the Grantee's Unique Entity Identifier (UEI)?
What is the Employer ID Number (EIN) or Tax ID Number (TIN) of the
Grantee?
For formula grantees only, are there any changes to your program year?
Yes or No.
Note: HUD must be notified of consolidated program year changes at
least two months before the date the program year would have ended
if it had not been lengthened, or at least two months before the end of
a proposed shortened program year.
If yes above, what is the revised program start date?
If yes above, what is the revised program end date?
What is the street address of the Grantee's office?
In what city is the Grantee's business address?
In what county is the Grantee's business address?
In what state is the Grantee's office located?
l What is the zip code for the Grantee's business address?
l What is the parent company of the Grantee (if applicable)?
l What department at the Grantee organization administers the grant?
l What is the Grantee organization's website address?
l What is the Facebook name or page of the Grantee?
l What is the Twitter handle of the Grantee?
l What are the cities of the primary service area of the Grantee?
l What are the counties of the primary service area of the Grantee?
What is the congressional district of the Grantee's business address?
l What is the congressional district of the Grantee's primary service area?
Is the grantee's Central Contractor Registration (CCR) status currently
active? Yes or No.
l What is the grantee's Central Contractor Registration (CCR) number?
Is there a waiting list(s) for HOPWA Housing Subsidy Assistance Services
in the Grantee service area? Yes or No.
Is the Grantee's System for Award Management (SAM) status currently
active for this report? Yes or No.
l What is the Grantee's SAM registration number for this report?
Does the Grantee provide HOPWA-funded services directly to clients?
Yes or No.
Does the Grantee take the allowable 3%Grantee Administration
allowance? Yes or No.
How much was expended on Grantee Administration?
Contact
(Contact Information for your Organization
Ctuestion
Contact Information for Authorizing Official
l What is the Authorizing Official contact name?
l What is the Authorizing Official contact title?
In what department does the Authorizing Official contact work?
l What is the Authorizing Official contact email?
l What is the Authorizing Official contact phone number (including
l What is the Authorizing Official contact fax number?
Contact Information for Reporting (APR/CAPER) Contact
l What is the Reporting contact name?
What is the Reporting contact title?
In what department does the Reporting contact work?
l What is the Reporting contact email?
l What is the Reporting contact phone number (including extension)?
l What is the Reporting contact fax number?
Contact Information for HMIS User
l What is the HMIS User contact name?
l What is the HMIS User contact title?
In what department does the HMIS User contact work?
l What is the HMIS User contact email?
l What is the HMIS User contact phone number (including extension)?
l What is the HMIS User contact fax number?
Contact Information for IDIS User
l What is the IDIS User contact name?
l What is the IDIS User contact title?
In what department does the IDIS User contact work?
l What is the IDIS User contact email?
l What is the IDIS User contact phone number (including extension)?
l What is the IDIS User contact fax number?
Contact Information for Primary Program Contact
l What is the Primary Program contact name?
l What is the Primary Program contact title?
In what department does the Primary Program contact work?
l What is the Primary Program contact email?
l What is the Primary Program contact phone number (including extension)?
l What is the Primary Program contact fax number?
Contact Information for Secondary Program Contact
l What is the Secondary Program contact name?
l What is the Secondary Program contact title?
In what department does the Secondary Program contact work?
l What is the Secondary Program contact email?
What is the contact Secondary Program phone number (including
extension)?
l What is the Secondary Program contact fax number?
Contact Information for Individuals Seeking Services
l What is the Services contact name?
What is the Services contact title?
In what department does the Services contact work?
What is the Services contact email?
l What is the Services contact phone number (including extension)?
l What is the Services contact fax number?
Responses
Narrative
Narrative Questions
Provide a maximum of 4,000 characters 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.
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.
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 operating year among different categories of
housing and geographic areas to address needs throughout the grant service area, consistent with
approved plans.
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.
Describe any program technical assistance needs and how they would benefit program
beneficiaries.
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.
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. Identify any evaluations, studies, or other assessments of
the HOPWA program that are available to the public.
Response - Maximum 4,000 characters for each question. lCharacter Count
Stewardship
Complete the Annual Report of Continued Usage for HOPWA Facility -Based
Stewardship Units, as defined in the Definitions, for EACH Stewardship Facility.
If more columns are needed, please contact the HOPWA Validation Team.
Question I Facility 1
What is the name of the stewardship facility?
What is the stewardship year (1-10) for this
facility?
What date did the facility operations begin?
How many HOPWA units are supported in this
stewardship facility?
What is the amount of non-HOPWA funds
expended on the stewardship facilities?
What is the name of the authorized official that
operates the facility?
What is the name of the primary program
contact at the facility?
What is the email address of the primary
program contact at the facility?
What is the phone number of the primary
program contact at the facility?
I Facility 2 I Facility 3 I Facility 4
0 0 0 0
0 0 0
0 0 0
Lei
0
Section 2:
HOPWA Consolidated APR/CAPER
Provider Workbook
Performance Report Cover
Housing Opportunities for Persons With AIDS (HOPWA) Program
Revised: 02/24/2022
Consolidated APR/CAPER — HOPWA Provider
OMB Number 2506-0133 (Expiration Date: 1213112024)
Overview
The public reporting burden for this collection of information is estimated to average 40.0 hours, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
Performance Reports for HOPWA formula grantees and competitive grantees provide HUD with annual information to support program evaluation and
measure program beneficiary outcomes related to maintaining housing stability; preventing homelessness; and improving access to care and support. This
collection of information consolidates the information in the APR and CAPER reports and clarifies reporting requirements, which will allow HUD's Office of
HIV/AIDS Housing to better respond to data calls from Congress and make better program decisions based on more relevant grantee annual data.
Reporting is required for all HOPWA grantees pursuant to 42 U.S.C. § 12911; 24 CFR §§ 574.520(a) and (b); 24 CFR § 91.520(f). The information collected
regarding grantees, their respective project sponsors, and the identities of HOPWA program participants will remain confidential pursuant to 42 U.S.C. §
12905(e) and 24 § CFR 574.440.
Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions to reduce this burden, to
Colette Pollard, Reports Management Officer, Department of Housing and Urban Development, 451 7th Street SW, Room 4176, Washington, DC 20410-
5000. When providing comments, please refer to OMB Control No. 2506-0133. HUD may not conduct and sponsor, and a person is not required to
respond to, a collection of information unless the collection displays a valid OMB Control Number.
HOPWA formula grantees are required to submit a Performance Report demonstrating coordination with other Consolidated Plan resources. HUD uses
the Performance Report data to obtain essential information on grant activities, project sponsors, housing sites, units and households, and beneficiaries
(which includes racial and ethnic data on program participants). The Consolidated Plan Management Process tool (CPMP) provides an optional tool to
integrate the reporting of HOPWA specific activities with other planning and reporting on Consolidated Plan activities.
In addition, grantees must comply with the Federal Funding Accountability and Transparency Act 2006 (Public Law 109-282), which requires grant
recipients to provide general information for all entities (including contractors and sub -contractors) receiving $25,000+ in federal funding.
HOPWA competitive grantees are required to submit a Performance Report for each operating year in which HOPWA grant funds were expended.
Information on each competitive grant is to be reported in a separate Performance Report. Grantees approved for "Other Activities," as detailed in their
grant agreement, are requested to report on their unique program accomplishments.
In addition, grantees must comply with the Federal Funding Accountability and Transparency Act 2006 (Public Law 109-282), which requires grant
recipients to provide general information for all entities (including contractors and sub -contractors) receiving $25,000+ in federal funding.
Continued -use Periods. Grantees that used HOPWA funding for new construction, acquisition, or substantial rehabilitation of a building or structure are
required to operate the building or structure for HOPWA-eligible beneficiaries for a ten (10) years period. If no further HOPWA funds are used to support
the facility, in place of completing the "CAP DEV" tab in the Performance Report Worksheet, the grantee must complete an Annual Report of Continued
Project Operation throughout the required use periods. This report is found on the "STEWARD" tab of this workbook. The required use period is three (3)
years if the rehabilitation is non -substantial.
Record Keeping. Names and other individual information must be kept confidential, as required by 24 CFR 574.440. However, HUD reserves the right to
review the information used to complete this report for grants management oversight purposes, except for recording any names and other identifying
information. In the case that HUD must review client -level data, no client names or identifying information will be retained or recorded. Information is
reported in aggregate to HUD without personal identification. Do not submit client or personal information in data systems to HUD.
HMIS. In connection with the development of the Department's standards for Homeless Management Information Systems (HMIS), universal data
elements are being collected for clients of HOPWA-funded homeless assistance Droiects. These project sponsor records would include: Name, Social
Security Number, Date of Birth, Ethnicity and Race, Gender, Veteran Status, Disabling Conditions, Residence Prior to Program Entry, Zip Code of Last
Permanent Address, Housing Status, Program Entry Date, Program Exit Date, Personal Identification Number, and Household Identification Number. These
are intended to match the elements under HMIS. The HOPWA program -level data elements include: Income and Sources, Non -Cash Benefits, HIV/AIDS
Status, Services Provided, Housing Status or Destination at the end of the operating year, Physical Disability, Developmental Disability, Chronic Health
Condition, Mental Health, Substance Abuse, Domestic Violence, Medical Assistance, and T-cell Count. Other HOPWA projects sponsors may also benefit
from collecting these data elements. HMIS local data systems must maintain client confidentiality by using a closed system in which medical information
and HIV status are only shared with providers that have a direct involvement in the client's case management, treatment and care, in line with the signed
release of information from the client.
Formula Operating Year. HOPWA formula grants are annually awarded for a three-year period of performance with three operating years. The
information contained in this Performance Report must represent a one-year period of HOPWA program operation that coincides with the grantee's
program year; this is the operating year. More than one HOPWA formula grant awarded to the same grantee may be used during an operating year and
the Performance Report must capture all formula grant funding used during the operating year. Project sponsor accomplishment information must also
coincide with the operating year this Performance Report covers. Any change to the period of performance requires the approval of HUD by amendment,
such as an extension for an additional operating year.
Competitive Operating Year. HOPWA competitive grants are awarded for a three-year period of performance with Performance Reports submitted for
each of the three operating years. The information contained in this Performance Report should reflect the grantee's operating year with the beginning
date determined at the time the grant agreement is signed. Project sponsor accomplishment information must coincide with the operating year this
Performance Report covers. Any change to the period of performance requires the approval of HUD by amendment, such as an extension for one
additional operating year. A PSH renewal/replacement grant start date would be coordinated with the close out of the existing grant.
Grantees with an approved extension period of less than 6-months must submit the Performance Report for the third year of the grant term at the end of
the approved extension period and incorporate data from the additional months. Grantees with an approved extension period of 6-months or more
must turn in a Performance Report at the end of the operating year and submit a separate extension Performance Report at the end of the extension
period.
Filing Requirements. Within 90 days of the completion of each operating year, grantees must submit their completed Performance Report to the CPD
Director in the grantee's State or Local HUD Field Office, and to the HOPWA Program Office: at HOPWA@hud.gov. Electronic submission to HOPWA
Program office is preferred. If electronic submission is not possible, please send an email to the HOPWA@hud.gov email inbox.
Definitions
Achieved Viral Suppression: When the load or volume of HIV virus present in a person's blood is measured at less than 200 copies per milliliter of blood.
Adjustment for Duplication: Enables the calculation of unduplicated output totals by accounting for the total number of households or units that received
more than one type of HOPWA assistance in a given service category such as HOPWA Subsidy Assistance or Supportive Services.
Administrative Costs: Costs for general management, oversight, coordination, evaluation, and reporting. By statute, grantee administrative costs are
limited to 3% of the total grant award, to be expended over the life of the grant. Project sponsor administrative costs are limited to 7% of the portion of
the grant amount they receive.
Anti-Retroviral Therapy: The combination of drugs used to treat HIV.
Area Median Income: The Department of Housing and Urban Development (HUD) sets income limits that determine eligibility for assisted housing
programs including the HOPWA program. HUD develops income limits based on Median Family Income estimates and Fair Market Rent area definitions
for each metropolitan area, parts of some metropolitan areas, and each non -metropolitan county. AMI values vary by location and are published at:
https://www.huduser.gov/portal/datasets/il.html
Beneficiary(ies): All members of a household (with or without HIV) who benefitted from HOPWA assistance during the operating year, NOT including the
HOPWA eligible individual (see definition).
Chronically Homeless Person: An individual or family who is homeless and lives or resides as an individual or family who a) lives or resides in a place not
meant for human habitation, a safe haven, or in an emergency shelter; b) has been homeless and living or residing in a place not meant for human
habitation, a safe haven, or in an emergency shelter continuously for at least one year or on at least four separate occasions in the last three years; and c)
has an adult head of household (or a minor head of household if no adult is present in the household) with a diagnosable substance use disorder, serious
mental illness, developmental disability (as defined in section 102 of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (42 U.S.C.
15002), post -traumatic stress disorder, cognitive impairments resulting from a brain injury, or chronic physical illness or disability, including the co -
occurrence of two or more of those conditions. Additionally, the statutory definition includes as chronically homeless a person who currently lives or
resides in an institutional care facility, including a jail, substance abuse or mental health treatment facility, hospital or other similar facility, and has
resided there for fewer than 90 days if such person met the other criteria for homeless prior to entering that facility. (See 42 U.S.C. 11360(2)) This does
not include doubled -up or overcrowding situations.
Disabling Condition: Evidencing a diagnosable substance use disorder, serious mental illness, developmental disability, chronic physical illness, or
disability, including the co -occurrence of two or more of these conditions. In addition, a disabling condition may limit an individual's ability to work or
perform one or more activities of daily living. An HIV/AIDS diagnosis is considered a disabling condition.
Facility -Based Housing Assistance: All eligible HOPWA Housing expenditures for or associated with supporting facilities including community residences,
SRO dwellings, short-term facilities, project -based rental units, master leased units, and other housing facilities approved by HUD.
Faith -Based Organization: Religious organizations of three types: (1) congregations; (2) national networks, which include national denominations, their
social service arms (for example, Catholic Charities, Lutheran Social Services), and networks of related organizations (such as YMCA and YWCA); and (3)
freestanding religious organizations, which are incorporated separately from congregations and national networks.
Grassroots Organization: An organization headquartered in the local community where it provides services; has a social services budget of $300,000 or
less annually, and six or fewer full-time equivalent employees. Local affiliates of national organizations are not considered "grassroots."
HOPWA Eligible Individual: The one (1) low-income person with HIV/AIDS who qualifies a household for HOPWA assistance. This person may be
considered "Head of Household." When the Performance Report asks for information on eligible individuals, report on this individual person only. Where
there is more than one person with HIV/AIDS in the household, the additional PWH/A(s), would be considered a beneficiary(s).
HOPWA Housing Information Services: Services dedicated to helping persons living with HIV/AIDS and their families to identify, locate, and acquire
housing. This may also include fair housing counseling for eligible persons who may encounter discrimination based on race, color, religion, sex, age,
national origin, familial status, or handicap/disability.
HOPWA Housing Subsidy Assistance Total: The unduplicated number of households receiving housing subsidies (TBRA, STRMU, Permanent Housing
Placement services and Master Leasing) and/or residing in units of facilities dedicated to persons living with HIV/AIDS and their families and supported
with HOPWA funds during the operating year.
Household: A single individual or a family composed of two or more persons for which household incomes are used to determine eligibility and for
calculation of the resident rent payment. The term is used for collecting data on changes in income, changes in access to services, receipt of housing
information services, and outcomes on achieving housing stability. Live -In Aides (see definition for Live -In Aide) and non -beneficiaries (e.g., a shared
housing arrangement with a roommate) who resided in the unit are not reported in the Performance Report.
Housing Stability: The degree to which the HOPWA project assisted beneficiaries to remain in stable housing during the operating year.
Improved HIV Viral Load: A reduction in the load or volume of HIV present in the HOPWA eligible individual's blood at the end of the reporting period
compared to the beginning of the reporting period. Most PLWHA who are engaged in medical care have routine laboratory tests. The HOPWA eligible
individual's latest laboratory report can be used to determine viral load.
In -kind Leveraged Resources: These are additional types of support provided to assist HOPWA beneficiaries such as volunteer services, materials, use of
equipment and building space. The actual value of the support can be the contribution of professional services, based on customary rates for this
specialized support, or actual costs contributed from other leveraged resources. In determining a rate for the contribution of volunteer time and services,
use the criteria described in 2 CFR 200. The value of any donated material, equipment, building, or lease should be based on the fair market value at time
of donation. Related documentation can be from recent bills of sales, advertised prices, appraisals, or other information for comparable property similarly
situated.
Leveraged Funds: The amount of funds expended during the operating year from non-HOPWA federal, state, local, and private sources by grantees or
sponsors in dedicating assistance to this client population. Leveraged funds or other assistance are used directly in or in support of HOPWA program
delivery.
Live -In Aide: A person who resides with the HOPWA Eligible Individual and who meets the following criteria: (1) is essential to the care and well-being of
the person; (2) is not obligated for the support of the person; and (3) would not be living in the unit except to provide the necessary supportive services.
See Code of Federal Regulations Title 24 Part 5.403 and the HOPWA Grantee Oversight Resource Guide for additional reference.
Master Leasing: Applies to a nonprofit or public agency that leases units of housing (scattered -sites or entire buildings) from a landlord and subleases the
units to homeless or low-income tenants. By assuming the tenancy burden, the agency facilitates housing of clients who may not be able to maintain a
lease on their own due to poor credit, evictions, or lack of sufficient income.
Medically Assisted Living Facilities: HOPWA facility -based housing that assists residents with most or all activities of daily living, such as meals, bathing,
dressing, and toileting. Regular medical care, supervision, and rehabilitation are also often available.
Nonbinary: A gender other than singularly female or male.
Operating Costs: Applies to facility -based housing only, for facilities that are currently open. Operating costs can include day-to-day housing function and
operation costs like utilities, maintenance, equipment, insurance, security, furnishings, supplies and salary for staff costs directly related to the housing
project but not staff costs for delivering services.
Outcome: The degree to which the HOPWA assisted household has been enabled to establish or maintain a stable living environment in housing that is
safe, decent, and sanitary, (per the regulations at 24 CFR 574.310(b)) and to reduce the risks of homelessness and improve access to HIV treatment and
other health care and support.
Output: The number of units of housing or households that receive HOPWA assistance during the operating year.
Permanent Housing Placement: A supportive housing service that helps establish the household in the housing unit, including but not limited to
reasonable costs for security deposits not to exceed two months of rent costs.
Program Income: Gross income directly generated from the use of HOPWA funds, including repayments. See grant administration requirements on
program income at 2 CFR 200.307.
Project -Based Rental Assistance (PBRA): A rental subsidy program that is tied to specific facilities or units owned or controlled by a project sponsor.
Assistance is tied directly to the properties and is not portable or transferable.
Project Sponsor Organizations: Per HOPWA regulations at 24 CFR 574.3, 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.
SAM: All organizations applying for a Federal award must have a valid registration active at sam.gov. SAM (System for Award Management) registration
includes maintaining current information and providing a valid DUNS number.
Short -Term Rent, Mortgage, and Utility (STRMU) Assistance: A time -limited, housing subsidy assistance designed to prevent homelessness and increase
housing stability. Grantees may provide assistance for up to 21 weeks in any 52-week period. The amount of assistance varies per client depending on
funds available, tenant need and program guidelines.
Stewardship Units: Units developed with HOPWA, where HOPWA funds were used for acquisition, new construction and rehabilitation that no longer
receive operating subsidies from HOPWA. Report information for the units is subject to the three-year use agreement if rehabilitation is non -substantial
and to the ten-year use agreement if rehabilitation is substantial.
Tenant -Based Rental Assistance (TBRA): TBRA is a rental subsidy program similar to the Housing Choice Voucher program that grantees can provide to
help low-income households access affordable housing. The TBRA voucher is not tied to a specific unit, so tenants may move to a different unit without
losing their assistance, subject to individual program rules. The subsidy amount is determined in part based on household income and rental costs
associated with the tenant's lease.
Transgender: Transgender is defined as a person who identifies with, or presents as, a gender that is different from his/her gender assigned at birth
VAWA Internal Emergency Transfers: Per 24 CFR 5.2005e, an emergency transfer under the VAWA protections refers to an emergency relocation of a
tenant to another unit where the tenant would not be categorized as a new applicant; that is, the tenant may reside in the new unit without having to
undergo an application process.
VAWA External Emergency Transfers: Per 24 CFR 5.2005e, an emergency transfer under the VAWA protections refers to an emergency relocation of a
tenant to another unit where the tenant would be categorized as a new applicant; that is, the tenant must undergo an application process in order to
reside in the new unit.
Veteran: A veteran is someone who has served on active duty in the Armed Forces of the United States. This does not include inactive military reserves or
the National Guard unless the person was called up to active duty.
Instructions
Instructions for Completing the HOPWA Performance Report Workbook
What is the HOPWA Performance Report Workbook?
This workbook provides annual performance data for HOPWA activities. This includes outputs (e.g., households served and
demographic information), outcomes (e.g., access to care and support outcomes) and expenditures (for HOPWA-eligible costs).
This data will be compiled by the HOPWA Formula or Competitive Grantee, as part of providing annual performance reporting to HUD.
Who completes this
form?
This workbook will be completed by any organization that conducts any HOPWA activities other than administrative activities. This
includes HOPWA Formula or Competitive Grantees that conduct other HOPWA activities besides administrative activities, and the
Project Sponsor organizations that Grantees contract to provide HOPWA services (as defined in 24 CFR 574.3).
There should be one organization's HOPWA activities reported in each workbook. Each organization should complete a separate
performance report workbook that only includes the HOPWA activities conducted by that organization.
What tabs should be completed for this report?
The Performance Report Workbook requires the completion of the following tabs:
DEM (Demographics) & Prior Living (see Note)
Leveraging
ATC (Access to Care) & Totals
ONLY PROJECT SPONSORS* should complete these tabs:
HOPWA Provider
CONTACT
*For Grantees that are approved to conduct Resource Identification or Technical Assistance activities, please report your expenditure
amounts for those budget line items in the HOPWA Provider tab. These are the only cells that you will need to complete in the HOPWA
Provider tab.
Note: Complete Prior Living information only for individuals served by TBRA, P-FBH, ST-TFBH or PHP.
The remaining tabs should ONLY be completed based on HOPWA services provided by the organization completing this workbook.
Leave tabs untouched if the activity is not provided by the organization.
• TBRA (Tenant -Based Rental Assistance)
• P-FBH (Permanent Facility -Based Housing)
• ST-TFBH (Short -Term or Transitional Facility -Based Housing)
• STRMU (Short -Term Rent, Mortgage and Utilities Assistance)
• PHP (Permanent Housing Placement Assistance)
• Housing Info (Housing Information Services)
• Supp Svcs (HOPWA Supportive Services)
• Other Competitive Activity
• CAP DEV (Capital Development)
• VA WA (Housing Transfers for Households Covered by the Violence Against Women Act)
Important Information
To ensure the integrity of this reporting form, please do not DELETE or ALTER any rows, columns, tabs, or the NAME
of the report.
This form requires the entry of data only where applicable, with no other actions required.
1 Enter text in empty cells next to questions.
2 Enter numbers where the entry reads "0" and the answer is an amount greater than zero.
SUBMISSION
INSTRUCTIONS
• Once complete, the Project Sponsor should return the entire workbook to the Grantee in the manner and timeline prescribed by the
Grantee.
• The report MUST be submitted in this Excel format.
• DO NOT alter the name of this file; return it to the Grantee with the file name as provided.
• The Grantee is responsible for reviewing this report and submitting it to HUD. Project Sponsors should not submit this report to HUD; only
to the Grantee.
• The Grantee may be contacted by HUD or a HUD contractor regarding the accuracy of this report.
• Please contact the Grantee if you require support submitting this form.
Project Sponsor Identification
Grant ID Grantee SponsorlD Sponsor
Provider Summary
Please complete for organizations designated to serve as project sponsor, i.e., organizations involved in the direct delivery
of services for client households, as defined by 24 CFR 574.3.
Project Sponsor Questions Responses
What is the organization's name?
What is the organization's Unique Entity Identifier (UEI)?
What is the organization's Employer ID Number (EIN) or Tax
ID Number (TIN)?
What is the HOPWA contract amount for this organization?
What is the organization's business street address?
In what city is the organization's business address?
In what county is the organization's business address?
In what state is the organization's business address?
What is the organization's business address zip code?
What is the organization's parent company, if applicable?
What department administers the organization's grant?
What is the organization's phone number (including
extension)?
What is the organization's fax number?
What is the organization's website?
What is the organization's Facebook page?
What is the organization's Twitter handle?
Is this a faith -based organization? Yes or No.
Is this a nonprofit organization? Yes or No.
0
Is this a grassroots organization? Yes or No.
What are the cities of the organization's primary service
area?
What are the counties of the organization's primary service
area?
In what congressional district is the organization located?
In what congressional district is the primary service area?
Is there a waiting list for HOPWA housing subsidy assistance
services in the organization's service area? Yes or No.
Project Sponsor Non -Direct Service Expenditures
What were the total HOPWA funds expended for
Administration costs?
How much was expended on Technical Assistance?
0
N
How much was expended on Resource Identification? 0
Contact
Contact Information for your Organization
Only organizations designated as project sponsors (see definition of "Project Sponsor Organization" in
Performance Report Cover tab) should complete this tab.
Question I Responses
Contact Information for Primary Program Contact
What is the Primary Program contact name?
What is the Primary Program contact title?
In what department does the Primary Program contact work?
What is the Primary Program contact email?
What is the Primary Program contact phone number (including extension)?
What is the Primary Program contact fax number?
Contact Information for Secondary Program Contact
What is the Secondary Program contact name?
What is the Secondary Program contact title?
In what department does the Secondary Program contact work?
What is the Secondary Program contact email?
What is the Secondary Program contact phone number (including extension)?
What is the Secondary Program contact fax number?
Contact Information for Individuals Seeking Services
What is the Services contact name?
What is the Services contact title?
In what department does the Services contact work?
What is the Services contact email?
What is the Services contact phone number (including extension)?
What is the Services contact fax number?
Demographics and Prior Living
A. For each racial
Of the total number of
category, how many
individuals reported
HOPWA-eligible
Individuals identified
Male
Female
Gender Nonbinary
Transgender Female
Transgender Male
Gender not Disclosed
for each racial
category, how many
as such?
also identify as
Hispanic or Latinx?
Younger
51 or
Younger
31-
51 or
Younger
51 or
Younger
51 or
Younger
51 or
Younger
51 or
18-30
31-50
18-30
18-30
31-50
18-30
31-50
18-30
31-50
18-30
31-50
Total Hispanic orLatinx
Than 18
Older
Than 18
50
Older
Than 18
Older
Than 18
Older
Than 18
Older
Than 18
Older
(Asian
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0 0
(Asian & White
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0 0
Black/African American
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0 0
Black/African American
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0 0
& White
American
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0 0
Indian/Alaskan Native
American
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0 0
Indian/Alaskan Native
& Black/African
American
American
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0 0
Indian/Alaskan Native
& White
Native Hawaiian/Other
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0 0
Pacific Islander
(Other Multi -Racial
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0 0
(White
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0 0
B. For each racial
category, how many
other household
members
(beneficiaries)
identified as such?
Male
Female
Gender Nonbinary
Transgender Female
Transgender Male
Gender not Disclosed
Of the total number of
individuals reported
for each racial
category, how many
also identify as
Hispanic or Latinx?
Younger
51 or
Younger
31-
51 or
Younger
51 or
Younger
51 or
Younger
51 or
Younger
51or
18-30
31-50
18-30
r18-30
31-SO
18-30
31-50
18-30
31-50
�183031-50
Total Hispanic or Latin
Than 18
Older
Than 18
50
Older
Than 18
Older
Than 18
Older
Than 18
Older
Than 18
Older
Asian 0 0 0 0 0 0 0 0 0 0 0 0
0
0
0
0
0
0
0
0
0
0
0
0
(Asian & White 0 0 0 0 0 0 0 0 0 0 0 0
0
0
0
0
0
0
0
0
0
0
0
0
Black/African American 0 0 0 0 0 0 0 0 0 0 0 0
0
0
0
0
0
0
0
0
0
0
0
0
Black/African American 0 0 0 0 0 0 0 0 0 0 0 0
0
0
0
0
0
0
0
0
0
0
0
0
& White
American 0 0 0 0 0 0 0 0 0 0 0 0
0
0
0
0
0
0
0
0
0
0
0
0
Indian/Alaskan Native
American 0 0 0 0 0 0 0 0 0 0 0 0
0
0
0
0
0
0
0
0
0
0
0
0
Indian/Alaskan Native
& Black/African
American
American 0 0 0 0 0 0 0 0 0 0 0 0
0
0
0
0
0
0
0
0
0
0
0
0
Indian/Alaskan Native
& White
Native Hawaiian/Other 0 0 0 0 0 0 0 0 0 0 0 0
0
0
0
0
0
0
0
0
0
0
0
0
Pacific Islander
Other Multi -Racial 0 0 0 0 0 0 0 0 0 0 0 0
0
0
0
0
0
0
0
0
0
0
0
0
White 0 0 0 0 0 0 0 0 0 0 0 0
0
0
0
0
0
0
0
0
0
0
0
0
Total number of other household members (beneficiaries) served with
HOPWA assistance (rows 16-25):
p
How many other household members (beneficiaries) are HIV+?
0
How many other household members (beneficiaries) are HIV negative or have
0
an unknown HIV status?
Complete Prior Living Situations for HOPWA-eligible Individuals served by TBRA,
P-FBH ST-TFBH, or PHP
How many HOPWA-eligible individuals continued receiving HOPWA assistance
0
from the previous year?
How many individuals newly receiving HOPWA assistance came from:
A place not meant for human habitation?
0
An emergency shelter?
0
A transitional housing facility for formerly homeless persons?
0
A permanent housing situation for formerly homeless persons?
0
A psychiatric hospital or other psychiatric facility?
0
A substance abuse facility?
0
A non -psychiatric hospital?
0
A foster care home?
0
Jail, prison, or a juvenile detention facility?
0
A rented room, apartment or house? 0
A house the individual owned? 0
Staying at someone else's house? 0
A hotel or motel paid for by the individual? 0
Any other prior living situation? 0
How many individuals newly receiving HOPWA assistance didn't report or 0
refused to report their prior living situation?
How many individuals newly receiving HOPWA assistance during this program
year reported a prior living situation of homelessness [place not for human 0
habitation, emergency shelter, transitional housing]:
Also meet the definition of experiencing chronic homelessness? 0
Also were veterans? 0
Leveraging
Report the source(s) of cash or in -kind leveraged federal, state, local or private resources identified in either the Consolidated or Annual Plan
(for formula grantees) or the grant proposal/application (for competitive grantees) and used in the delivery of the HOPWA program and the
amount of leveraged dollars.
What is the amount and type of leveraged funding that was provided by Funding for this Report Was this a Housing Subsidy Assistance?
any of these sources? Yes or No.
ESG 0
HOME 0
Ryan White 0
Continuum of Care (CoQ 0
Low -Income Housing Tax Credit 0
Housing Choice Voucher Program 0
Private grants 0
In -kind resources 0
Grantee cash
0
Other types of private or public funding:
Other FUNDING-1
0
Other FUNDING-2
0
Other FUNDING-3
0
Other FUNDING-4
0
Other FUNDING-5
0
Other FUNDING-6
0
Other FUNDING-7
0
Other FUNDING-8
0
Other FUNDING-9
0
Other FUNDING_10
0
Other FUNDING_11
0
Other FUNDING_12
0
Other FUNDING_13
0
Other FUNDING_14
0
Other FUNDING_15
0
Program Income
What was the amount of program income collected from resident rent
payments in the program year?
What was the amount of program income collected from other sources 0
(non-resident payments) in the program year?
What was the amount of resident rent payment that residents paid 0
directly to private landlords?
Uses of Program Income
What was the amount of total program income that was spent on housing 0
assistance in the program year?
What was the amount of total program income that was spent on 0
supportive services or other non -housing costs in the program year?
Tenant Based Rental Assistance (TBRA)
Complete this section for all Households served with HOPWA Tenant -Based Rental Assistance (TBRA) by your organization
in the reporting year.
Question
TBRA Households Served and Expenditures
How many households were served with HOPWA TBRA assistance?
What were the total HOPWA funds expended for TBRA rental assistance?
Other (Non-TBRA) Rental Assistance
Households Served and Expenditures (Other Non-TBRA Rental Assistance activities must
be approved in the grant agreement).
How many total households were served with Other (non-TBRA) Rental Assistance?
What were the total HOPWA funds expended for Other (non-TBRA) Rental Assistance, as
approved in the grant agreement?
Describe the Other (non-TBRA) Rental Assistance provided. (150 characters).
This Report
I
J]
TBRA Household Total (TBRA + Other) 0
Income Levels for Households Served by this Activity 0
What is the number of households with income below 30% of Area Median Income? 0
What is the number of households with income between 31% and 50% of Area Median
Income?
What is the number of households with income between 51% and 80% of Area Median
Income?
Sources of Income for Households Served by this Activity
I
A
How many households accessed or maintained access to the following sources of income 0
in the past year?
Earned Income from Employment 0
Retirement 0
SSI 0
SSDI 0
Other Welfare Assistance (Supplemental Nutrition Assistance Program, WIC, TANF, 0
etc.)
Private Disability Insurance 0
Veteran's Disability Payment (service or non -service connected payment)
0
Regular contributions or gifts from organizations or persons not residing in the
0
residence
Worker's Compensation
0
General Assistance (GA), or local program
0
Unemployment Insurance
0
Other Sources of Income
0
How many households maintained no sources of income?
0
Medical Insurance for Households Served by this Activity
How many households accessed or maintained access to the following sources of medical
insurance in the past year?
MEDICAID Health Program or local program equivalent
0
MEDICARE Health Insurance or local program equivalent
0
Veterans Affairs Medical Services
0
AIDS Drug Assistance Program
0
State Children's Health Insurance Program (SCHIP) or local program equivalent
0
Ryan White -funded Medical or Dental Assistance
0
Health Outcomes for Households Served by this Activity
How many HOPWA-eligible individuals served with TBRA this year have ever been
0
prescribed Anti-Retroviral Therapy?
How many HOPWA-eligible persons served with TBRA have shown an improved viral load
0
or achieved viral suppression?
Longevity for Households Served by this Activity
0
How many households have been served with TBRA for less than one year?
0
How many households have been served with TBRA for more than one year, but less than
0
five years?
How many households have been served with TBRA for more than five years, but less
0
than 10 years?
How many households have been served with TBRA for more than 10 years, but less than
0
15 years?
How many households have been served with TBRA for more than 15 years?
0
Housing Outcomes for Households Served by this Activity
I 0
How many households continued receiving HOPWA TBRA assistance into the next year?
0
How many households exited to other HOPWA housing programs?
0
How many households exited to other housing subsidy programs?
0
How many households exited to an emergency shelter?
How many households exited to private housing?
How many households exited to transitional housing (time limited - up to 24 months)?
How many households exited to an institutional arrangement expected to last less than
six months?
How many households exited to institutional arrangement expected to last more than six
months?
How many households exited to a jail/prison term expected to last less than six months?
How many households exited to a jail/prison term expected to last more than six months?
How many households exited to a situation that isn't transitional, but is not expected to
last more than 90 days and their housing situation after those 90 days is uncertain?
How many households exited to a place not meant for human habitation?
How many households were disconnected from care?
How many of the HOPWA eligible individuals died?
Permanent Facility Based Housing
Complete this section for all Households served with HOPWA
Permanent Facility -Based Housing assistance by your
organization in the reporting year.
Question
Facility Information
What is the name of the housing facility?
Is the facility a medically assisted living facility? Yes or No.
Was the housing facility placed into service during this program year?
Yes or No.
For housing facilities placed into service during this program year,
how many units were placed into service? [Do not complete if facility
placed in service in prior years.]
Leasing -- Households and Expenditures Served by this Activity
How many households received Permanent Facility -Based Housing
Leasing support for each facility?
What were the HOPWA funds expended for Permanent Facility -Based
Housing Leasing Costs for each facility?
Operating -- Households and Expenditures Served by this Activity
How many households received Permanent Facility -Based Housing
Operating support for each facility?
What were the HOPWA funds expended for Permanent Facility -Based
Housing Operating Costs for each facility?
Other Housing Support -- Households and Expenditures Served by
this Activity
How many households received Other types of Permanent Facility -
Based Housing support for each facility?
What were the HOPWA funds expended for Other types of
Permanent Facility -Based Housing for each facility?
For households served with Other Permanent Facility -Based Housing,
what type of service were they provided? (150 characters)
PFBH Deduplication
There are sixty columns for
facilities. If more columns are
needed, please contact the HOPWA
Validation Team.
Facility 1 Facility 2 I Facility 3
0 0
0 0
0 0
0 0
0 0
0 0
0 0
[I
0
C
0
A
t•
'7
How many households received more than one type of PFBH for each
facility? (Leasing, Operating, Other)
0
0
0
Total Deduplicated Household Count
0
0
0
Income Levels for Households Served by this Activity
What is the number of households with income below 30% of Area
0
0
0
Median Income?
What is the number of households with income between 31% and
0
0
0
50% of Area Median Income?
What is the number of households with income between 51% and
0
0
0
80% of Area Median Income?
Sources of Income for Households Served by this Activity
How many households accessed or maintained access to the following
sources of income in the past year?
Earned Income from Employment
0
0
0
Retirement
0
0
0
SSI
0
0
0
SSDI
0
0
0
Other Welfare Assistance (Supplemental Nutrition Assistance
0
0
0
Program, WIC, TANF, etc.)
Private Disability Insurance
0
0
0
Veteran's Disability Payment (service or non -service connected
0
0
0
payment)
Regular contributions or gifts from organizations or persons not
0
0
0
residing in the residence
Worker's Compensation
0
0
0
General Assistance (GA), or local program
0
0
0
Unemployment Insurance
0
0
0
Other Sources of Income
0
0
0
How many households maintained no sources of income?
0
0
0
Medical Insurance for Households Served by this Activity
How many households accessed or maintained access to the following
sources of medical insurance in the past year?
MEDICAID Health Program or local program equivalent
0
0
0
MEDICARE Health Insurance or local program equivalent
0
0
0
Veterans Affairs Medical Services
0
0
0
AIDS Drug Assistance Program
0
0
0
State Children's Health Insurance Program (SCHIP) or local program
0
0
0
equivalent
Ryan White -funded Medical or Dental Assistance
0
0
0
Longevity for Households Served by this Activity
How many households have been served by permanent facility -based
0
0
0
housing for less than one year?
How many households have been served by permanent facility -based
0
0
0
housing for more than one year, but less than 5 years?
How many households have been served by permanent facility -based
0
0
0
housing for more than 5 years, but less than 10 years?
How many households have been served by permanent facility -based
0
0
0
housing for more than 10 years, but less than 15 years?
How many households have been served by permanent facility -based
0
0
0
housing for more than 15 years?
Health Outcomes for Households Served by this Activity
How many HOPWA-eligible individuals served with PFBH this year
0
0
0
have ever been prescribed Anti-Retroviral Therapy, by facility?
How many HOPWA-eligible persons served with PFBH have shown an
0
0
0
improved viral load or achieved viral suppression, by facility?
Housing Outcomes for Households Served by this Activity
How many households continued receiving this type of HOPWA
0
0
I
assistance into the next year?
How many households exited to other HOPWA housing programs?
0
0
0
How many households exited to other housing subsidy programs?
0
0
0
How many households exited to an emergency shelter?
0
0
0
How many households exited to private housing?
0
0
0
How many households exited to transitional housing (time limited -
0
0
0
up to 24 months)?
How many households exited to institutional arrangement expected
0
0
0
to last less than six months?
How many households exited to institutional arrangement expected
0
0
0
to last more than six months?
How many households exited to a jail/prison term expected to last
0
0
0
less than six months?
How many households exited to a jail/prison term expected to last
0
0
0
more than six months?
How many households exited to a situation that isn't transitional, but 0 0 0
is not expected to last more than 90 days and their housing situation
after those 90 days is uncertain?
How many households exited to a place not meant for human 0 0 0
habitation?
How many households were disconnected from care? 0 0 0
How many of the HOPWA eligible individuals died? 0 0 0
Short -Term and Transitional Facility -Based Housing
Complete this section for Facilities, Households served with
HOPWA Short -Term or Transitional Facility -Based Housing
assistance by your organization in the reporting year.
Examples include Short -Term and Transitional Housing Types, Facility
Based Housing with a tenure of fewer than 24 months, short-term
treatment or health facilities, hotel -motel vouchers.
There are sixty columns for facilities. If more
columns are needed, please contact the HOPWA
Validation Team.
Question Facility 1
Facility 2
Facility Information
What is the name of the housing facility?
Is the facility a medically assisted living facility? Yes or No.
Was the housing facility placed into service during this program year?
Yes or No.
For housing facilities placed into service during this program year, how
0 0
many units were placed into service? [Do not complete if facility placed
in service in prior years.]
Leasing -- Households and Expenditures Served by this Activity
How many households received Transitional/Short-Term Facility -Based
0 0
Housing Leasing support for each facility?
What were the HOPWA funds expended for Transitional/Short-Term
0 0
Facility -Based Housing Leasing Costs for each facility?
Operating -- Households and Expenditures Served by this Activity
How many households received Transitional/Short-Term Facility -Based
0 0
Housing Operating support for each facility?
What were the HOPWA funds expended for Transitional/Short-Term
0 0
Facility -Based Housing Operating Costs for each facility?
Hotel -Motel -- Households and Expenditures Served by this Activity
How many households received Hotel -Motel cost support for each
0 0
facility?
What were the HOPWA funds expended for Hotel -Motel Costs for each
0 0
facility?
Other Housing Support -- Households and Expenditures Served by this
Activity
Facility 3
0
0
0
0
0
0
0
How many households received Other types of Transitional/Short-Term
Facility -Based Housing support for each facility?
What were the HOPWA funds expended for Other types of
Transitional/Short-Term Facility -Based Housing for each facility?
For households served with Other Transitional/Short-Term Facility -
Based Housing, what type of service were they provided? (150
characters)
ST-TFBH Deduplication
How many households received more than one type of ST-TFBH for
each facility? (Leasing, Operating, Hotel -Motel, Other)
Total Deduplicated Household Count
Income Levels for Households Served by this Activity
What is the number of households with income below 30% of Area
Median Income?
What is the number of households with income between 31% and 50%
of Area Median Income?
What is the number of households with income between 51% and 80%
of Area Median Income?
Sources of Income for Households Served by this Activity
How many households accessed or maintained access to the following
sources of income in the past year?
Earned Income from Employment
Retirement
SSI
SSDI
Other Welfare Assistance (Supplemental Nutrition Assistance
Program, WIC, TANF, etc.)
Private Disability Insurance
Veteran's Disability Payment (service or non -service connected
payment)
Regular contributions or gifts from organizations or persons not
residing in the residence
Worker's Compensation
General Assistance (GA), or local program
Unemployment Insurance
Other Sources of Income
How many households maintained no sources of income?
0
f@]
0
0 0
0
0
0
0
X
0
f@]
0 0
0
0 0
0 0
A
N
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
Medical Insurance for Households Served by this Activity
How many households accessed or maintained access to the following
sources of medical insurance in the past year?
MEDICAID Health Program or local program equivalent
MEDICARE Health Insurance or local program equivalent
Veterans Affairs Medical Services
AIDS Drug Assistance Program
State Children's Health Insurance Program (SCHIP) or local program
equivalent
Ryan White -funded Medical or Dental Assistance
Longevity for Households Served by this Activity
How many households have been served by short-term/transitional
facility -based housing for less than one year?
How many households have been served by short-term/transitional
facility -based housing for more than one year, but less than five years?
How many households have been served by short-term/transitional
facility -based housing for more than five years, but less than 10 years?
How many households have been served by short-term/transitional
facility -based housing for more than 10 years, but less than 15 years?
How many households have been served by short-term/transitional
facility -based housing for more than 15 years?
Housing Outcomes for Households Served by this Activity
How many households continued receiving this type of HOPWA
assistance into the next year?
How many households exited to other HOPWA housing programs?
How many households exited to other housing subsidy programs?
How many households exited to an emergency shelter?
How many households exited to private housing?
How many households exited to transitional housing (time limited - up
to 24 months)?
How many households exited to institutional arrangement expected to
last less than six months?
How many households exited to institutional arrangement expected to
last more than six months?
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
IC
0
How many households exited to a jail/prison term expected to last less 0 0
than six months?
IC
0
How many households exited to a jail/prison term expected to last more
than six months?
How many households exited to a situation that isn't transitional, but is
not expected to last more than 90 days and their housing situation after
those 90 days is uncertain?
How many households exited to a place not meant for human
habitation?
How many households were disconnected from care?
How many of the HOPWA eligible individuals died?
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
Short -Term Rent, Mortgage and Utility (STRMU)
Complete this section for all Households served with HOPWA Short -Term Rent, Mortgage, and Utilities Assistance
(STRMU) by your organization in the reporting year.
Question This Report
Households Served by this Activity - STRMU Breakdown
a. How many households were served with STRMU mortgage assistance only?
b. How many households were served with STRMU rental assistance only?
c. How many households were served with STRMU utilities assistance only?
d. How many households received more than one type of STRMU assistance?
STRMU Households Total 0
STRMU Expenditures
What were the HOPWA funds expended for the following budget line items?
STRMU mortgage assistance
STRMU rental assistance
STRMU utility assistance
Total STRMU Expenditures
Income Levels for Households Served by this Activity 0
What is the number of households with income below 30% of Area Median Income?
What is the number of households with income between 31% and 50% of Area Median Income?
What is the number of households with income between 51% and 80% of Area Median Income?
Sources of income for Households Served by this Activity
How many households accessed or maintained access to the following sources of income in the past year? 0
Earned Income from Employment
Retirement
SSI
SSDI
Other Welfare Assistance (Supplemental Nutrition Assistance Program, WIC, TANF, etc.)
Private Disability Insurance
Veteran's Disability Payment (service or non -service connected payment)
N
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Regular contributions or gifts from organizations or persons not residing in the residence
Worker's Compensation
General Assistance (GA), or local program
Unemployment Insurance
Other Sources of Income
How many households maintained no sources of income?
Medical Insurance for Households Served by this Activity
How many households accessed or maintained access to the following sources of medical insurance in the
past year?
MEDICAID Health Program or local program equivalent
MEDICARE Health Insurance or local program equivalent
Veterans Affairs Medical Services
AIDS Drug Assistance Program
State Children's Health Insurance Program (SCHIP) or local program equivalent
Ryan White -funded Medical or Dental Assistance
Longevity for Households Served by this Activity 0
How many households have been served by STRMU for the first time this year?
How many households also received STRMU assistance during the previous STRMU eligibility period?
How many households received STRMU assistance more than twice during the previous five eligibility
periods?
How many households received STRMU assistance during the last five consecutive eligibility periods?
Housing Outcomes for Households Served by this Activity 0
How many households continued receiving this type of HOPWA assistance into the next year?
How many households exited to other HOPWA housing programs?
How many households exited to other housing subsidy programs?
How many households exited to an emergency shelter?
How many households served with STRMU were able to maintain a private housing situation without
subsidy?
How many households exited to transitional housing (time limited - up to 24 months)?
How many households exited to institutional arrangement expected to last less than six months?
How many households exited to institutional arrangement expected to last more than six months?
How many households exited to a jail/prison term expected to last less than six months?
How many households exited to a jail/prison term expected to last more than six months?
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
L
Il
How many households exited to a situation that isn't transitional, but is not expected to last more than 90 0
days and their housing situation after those 90 days is uncertain?
How many households exited to a place not meant for human habitation? 0
How many households were disconnected from care? 0
How many of the HOPWA eligible individuals died? 0
How many households are likely to need additional Short -Term Rent, Mortgage and Utilities assistance to 0
maintain the current housing arrangements?
Permanent Housing Placement (PHP)
Complete this section for all Households served with HOPWA Permanent Housing Placement (PHP) assistance by your organization in
the reporting year.
Question This Report
Households Served by this Activity
How many households were served with PHP assistance?
PHP Expenditures for Households Served by this Activity
What were the HOPWA funds expended for PHP?
Sources of Income for Households Served by this Activity
How many households accessed or maintained access to the following sources of income in the past year?
Earned Income from Employment
Retirement
SSI
SSDI
Other Welfare Assistance (Supplemental Nutrition Assistance Program, WIC, TANF, etc.)
Private Disability Insurance
Veteran's Disability Payment (service or non -service connected payment)
Regular contributions or gifts from organizations or persons not residing in the residence
Worker's Compensation
General Assistance (GA), or local program
Unemployment Insurance
Other Sources of Income
How many households maintained no sources of income?
Medical Insurance for Households Served by this Activity
How many households accessed or maintained access to the following sources of medical insurance in the past year?
MEDICAID Health Program or local program equivalent
MEDICARE Health Insurance or local program equivalent
Veterans Affairs Medical Services
AIDS Drug Assistance Program
State Children's Health Insurance Program (SCHIP) or local program equivalent
Ryan White -funded Medical or Dental Assistance
0
Housing Outcomes for Households Served by this Activity 0
0
0
1
0
0
0
0
0
0
0
0
In the context of PHP, "exited" means the housing situation into which the household was placed using the PHP assistance.
How many households exited to other HOPWA housing programs?
How many households exited to other housing subsidy programs?
How many households exited to private housing?
Housing Information Services
Complete for all households served with HOPWA-funded Housing Information Services by your organization
in the reporting year.
See definition of "Housing Information Services" on "Performance Report Cover" tab.
Question
This Report
Households Served by this Activity
How many households were served with housing information services?
0
Housing Information Services Expenditures
What were the HOPWA funds expended for Housing Information Services?
0
Supportive Services
Complete for all households served with HOPWA funded Supportive Services by your organization in the reporting
year.
Note that this table also collects HOPWA Supportive Service expenditures.
Questions This Report
Households and Expenditures for Supportive Service Types Number of Households Expenditures
What were the expenditures and number of households for each of the
following types of supportive services in the program year?
Adult Day Care and Personal Assistance
0
0
Alcohol -Drug Abuse
0
0
Child Care
0
0
Case Management
0
0
Education
0
0
Employment Assistance and Training
0
0
Health/Medical Services
0
0
Legal Services
0
0
Life Skills Management
0
0
Meals/Nutritional Services
0
0
Mental Health Services
0
0
Outreach
0
0
Transportation
0
0
Any other type of HOPWA funded, HUD approved supportive service?
0
0
What were the other type(s) of supportive services provided? (150
characters)
Deduplication of Supportive Services
How many households received more than one of any type of
0
Supportive Services?
Access to Care (ATC) and Totals
Housing
Other
Activity Review
TBRA
P-FBH
ST-TFBH
STRMU
PHP
SUPP SVC
Competitive
Info
Activity
Total Households Served in ALL
0
0
0
0
0
0
0
0
Activities from this report for
each Activity.
Housing Subsidy Assistance Household Count Deduplication
Total Housing Subsidy Assistance (from the TBRA, P-FBH, ST-
FBH, STRMU, PHP, Other Competitive Activity counts above)
How many households received more than one type of HOPWA
Housing Subsidy Assistance for TBRA, P-FBH, ST-FBH, STRMU, 0
PHP, Other Competitive Activity?
Total Unduplicated Housing Subsidy Assistance Household
0
Count
Access to Care (ATC)
Complete HOPWA Outcomes for Access to Care and Support for all
households served with HOPWA housing assistance and "other
competitive activities" in the reporting year.
Questions This Report
How many households had contact with a case manager? 0
How many households developed a housing plan for 0
maintaining or establishing stable housing?
How many households accessed and maintained medical 0
insurance and/or assistance?
How many households had contact with a primary health care 0
provider?
How many households accessed or maintained qualification for 0
sources of income?
How many households obtained/maintained an income- 0
producing job during the program year (with or without any
HOPWA-related assistance)?
Subsidy Assistance with Supportive Service, Funded Case Management
Questions This Report
How many households received any type of HOPWA Housing 0
Subsidy Assistance and HOPWA Funded Case Management?
How many households received any type of HOPWA Housing 0
Subsidy Assistance and HOPWA Supportive Services?
Capital Development
Complete for all HOPWA Facility -based Capital
Development Projects that received Capital
Development funds in this reporting year. This
includes projects that received HOPWA Capital
Development funds and opened to residents in
this reporting year.
Note: Scattered site facilities may be reported as one
facility.
Question Facility 1
Facility Information
What is the name of the facility using HOPWA for
capital development (acquisition or rehabilitation)?
Capital Development means
the use of HOPWA funds to
construct, acquire, or
rehabilitate a housing facility.
Facility 2 Facility 3 Facility 4
For facilities being rehabilitated, what was the total 0 0 0
amount of funding spent on rehabilitation?
What type of development was funded (new
construction, rehabilitation, acquisition)?
For facilities being rehabilitated only, what is the 0 0 0
final value of the building after rehabilitation is
complete?
What type of housing (Permanent or Short-
term/Transitional) was developed?
For Capital Development facilities, what is the
purchase or lease date of the property?
For Capital Development facilities, what is the date
the construction or rehabilitation started (if
applicable)?
Capital Development Expenditures
How much was expended in this year on 0 0 0
acquisition, for each facility?
A
A
0
How much was expended on rehabilitation, for each
0
0
0
0
facility?
How much was expended on new construction, for
0
0
0
0
each facility?
Was the development facility placed into service
during this program year? Yes or No.
Complete for Capital Development Facilities
Opened This Year ONLY. If the facility was not
opened this year, skip this section.
How many total units were placed into service this
0
0
0
0
year?
What date did the supportive services begin?
What date was the construction or rehabilitation
completed?
What date did residents begin to occupy the
facility?
Is there a waiting list maintained for the facility? Yes
or No.
If there is a waiting list, how many households are
0
0
0
0
on the waiting list?
How many total units (HOPWA and non-HOPWA
0
0
0
0
units) were developed in this facility?
How many units in this facility were developed with
0
0
0
0
HOPWA funds?
Total Units
Total Units
504
Total Units
Designated
Total Units
Accessible
Designated for
For all Facilities
to Assist
Energy -Star
— Mobility
the Chronically
the
Compliant
Units —
Homeless
Homeless
Sensory
Units
For units constructed (new) and/or acquired with or
without rehab: 0 0 0 0
For rental units rehabbed: 0 0 0 0
For homeownership units constructed (if approved): 0 0 0 0
Violence Against Women Act (VAWA)
Complete for all households who requested
Violence Against Women Act (VAWA)
protections per 24 CFR 5.2005 with your
organization in the reporting year.
Question
This Report
How many internal emergency transfers were
requested? 0
How many internal emergency transfers were
granted? 0
How many external emergency transfers were
requested? 0
How many external emergency transfers were
granted? 0
How many emergency transfers were denied? 0
Other Competitive Activity
Only Competitive Grantees with an "Other Housing Activity"
approved in their grant agreement should complete this tab.
"Other" Housing Activities -- Households and This Report
Expenditures Served by this Activity
How many households were served with "Other
Housing Activity" assistance?
What were the HOPWA funds expended for
"Other Housing Activity" assistance?
What is the "Other" HOPWA budget line item
approved in the grant agreement? (150
characters)
Contract and Subcontract Activity U.S. Department of Housing and Urban Development OMB Approval No.: 2577-0088 OMB
Approval No.: 2502-0355
Public reporting burden for this collection of information is estimated to average .5 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The
Information is voluntary. HUD may not collect this information, and you are not required to complete this form, unless it displays a currently valid OMB Control Number.
Executive Orders dated July 14, 1983, directs the Minority Business Development Plans shall be developed by each Federal Agency and the these annual plans shall establish minority business development objectives. The information is used by HUD to monitor and evaluate MBE activities against
the total program activity and the designated minority business enterprise (MBE) goals. The Department requires the information to provide guidance and oversight for programs for the development of minority business enterprise concerning Minority Business Development. If the information is
not collected HUD would not be able to establish meaningful MBE goals nor evaluate MBE performance against these goals.
Privacy Act Notice = The United States Department of Housing and Urban Development, Federal Housing Administration, is authorized to solicit the Information requested in this form by virtue of Title 12, United States Code, Section 1701 et seq., and regulation. It will not be disclosed or
relesed outside the United States Department of Housing and Urban Development without your consent, except as required or permitted by Law.
1. Grantee/Project Owner/Developer/Sponsor/Builder/Agency
Check if 2. Location (City, State Zip Code)
PH
IH
CPD
Housing
3a. Name of Contact Person
3b. Phone Number (Including Area Code)
4. Reporting
Period
5. Program Code (Not applicable for CPD programs.)
6. Date Submitted to Field Office
See explanation of Codes at bottom of Page Use a
❑
❑
Oct. 1 - Sept. 30 (Annual -FY)
separate sheet for each program code.
Contractor or
Grant/Project Number or HUD
Subcontractor
Case Number or other
Amount of Type of Trade
Business
Subcontractor
Contractor/Subcontractor Name and Address
identification of property,
Contract or Code
Racial/Ethnic
Woman Owned Business Prime Contractor Identification HD)
Identification (11))
7j.
subdivision, dwelling unit, etc.
Subcontact (See below)
(See below)
(Yes or No) Number
See. 3
Number Sec. 3
7a.
7b. 7c.
7d.
7e. 7f.
7g.
7h 7i.
Name Street City State Zip
CPD:
I = New Construction
2 = Education/Traming
3 = Other
7c: Type of Trade Codes:
Housing/Public Housing:
1 —New Construction 6 = Professional
2 — Substantial Rehab. 7 = Tenant Services
3 — Repair 8 = Education/Traming
4 = Service 9 = Arch./Engrg. Appraisal
5 — Project Mangt. 0 = Other
7d: Racial/Ethnic Codes: 5: Program Codes (Complete for Housing and Public and Indian Housing programs only):
1 = White Americans
1 = All Insured, including Sections
5 = Section 202
2 = Black Americans
2= Flexible Subsidy
6 = HUD -Held (Management)
3 = Native Americans
3 = Section 8 Noninsured, Non-HFDA
7 — Public/India Housing
4 = Hispanic Americans
4 = Insured (Management)
8 — Section 811
5=Asian/Pacific Americans
6 = Hasidic Jews
Previous editions are obsolete. form HUD-2516 (8/98)
EXHIBIT "J"
DUTIES OF THE PARTIES
USE OF NEIGHBORHOOD SERVICES DEPARTMENT
COMMUNITY CENTERS
HOPWA PSA CONTRACT 2023-24-- EXHIBIT "J" — DUTIES OF THE PARTIES —USE OF
NEIGHBORHOOD SERVICES DEPARTMENT COMMUNITY CENTERS Page 1
AGENCY
DUTIES OF THE PARTIES
USE OF NEIGHBORHOOD SERVICES DEPARTMENT
COMMUNITY CENTERS
A2enev's Responsibilities:
Agency will perform the following in relation with the use of Community Center:
• Agency will furnish the Center Coordinator with a schedule of Program activities at least
four weeks prior to their occurrence.
• Agency will, at its sole expense, furnish materials, supplies, copies and conduct a structured
Program.
• Agency will ensure that the designated Community Center space is maintained in a neat
and orderly fashion.
• Agency will ensure that the City's standards are maintained regarding security; cleanliness
and communication between and among programs housed at the Community Center and
will ensure cooperation with other Community Center staff and agencies/programs.
• Agency will report to the Center Coordinator or designee for problems immediately
if/when problems occur.
• Agency will work with the Center Coordinator or designee to schedule any use of the
Community Center for related activities outside of agencies designated meeting time and/or
the Community Center's regular days and hours.
• Agency will maintain sole responsibility and liability for its employees, volunteers and
separate contractors for their actions.
• Agency shall ensure that each of its employees, volunteers and participants desiring to
participate in Community Center -sponsored programs/activities are aware of the
requirement to have a current community center membership card to participate.
• Agency agrees to perform background screenings and checks on staff and volunteers, with
such screenings and checks meeting or exceeding the requirements that the City imposes
for checks and screenings on staff, volunteers and participants in the City's own programs.
• Agency will provide the Center Coordinator with designated staff contact information for
the purposes of emergencies (center closing, schedule changes or scheduled maintenance)
Citv's Responsibilities:
HOPWA PSA CONTRACT 2023-2024 -- EXHIBIT "J" — DUTIES OF THE PARTIES —USE OF
NEIGHBORHOOD SERVICES DEPARTMENT COMMUNITY CENTERS Page I
City will perform the following in relation with Agency's use of a Community Center:
• City will provide space for conducting the Program, including basic utilities and will also
supply the Agency with appropriate facility access. For purposes of this Contract, basic
utilities shall not include telephone or computer service, which shall remain the sole
responsibility of the Agency.
• City will ensure that the reserved space is set up with appropriate tables and chairs to
accommodate program and/or services.
• City will not be responsible for any additional security other than what is currently
available at the Community Center.
• City assumes no liability or responsibility for the loss of any personal property or office
contents of the Agency, its agents, employees, volunteers, participants or licensees while
at the Community Center.
• City will allow the Agency to conduct properly scheduled classes and other Program
related activities during the days and hours specified in Exhibit "A" PROGRAM
SUMMARY*. In addition, City may, but is not required, through the Center Coordinator,
allow Agency to schedule other classes and Program related activities outside of the days
and hours specified in Exhibit "A" PROGRAM SUMMARY.
• City will maintain sole responsibility and liability for its employees, volunteers and
separate contractors for their actions.
• City will have the discretion to put the Agency in any available room. If placed in a
different location, it is to be only one room.
*The City is closed in observance of the following holidays:
New Year's Day (January 1st)
M.L.K. Jr. Day (Third Monday of January)
Memorial Day (Last Monday in May)
Independence Day (July 4th)
Labor Day (First Monday in September)
Thanksgiving Day (Fourth Thursday of November)
Day after Thanksgiving (Fourth Friday in November)
Christmas Day (December 25th)
"City of Fort Worth observes the above holidays on Friday if they fall on Saturday and on a Monday if they
fall on Sunday.
Additionally, the Community Centers are utilized as shelters during an emergency. If the
Community Center will be closed due to an emergency, Center Coordinator or designee will
inform Agency of the closure.
HOPWA PSA CONTRACT 2023-2024 -- EXHIBIT "J" — DUTIES OF THE PARTIES —USE OF
NEIGHBORHOOD SERVICES DEPARTMENT COMMUNITY CENTERS Page 2
EXHIBIT "K"
NOTICE OF BENEFICIARY RIGHTS
HOPWA PSA CONTRACT -- EXHIBIT "K" — NOTICE OF BENEFICIARY RIGHTS Page 1
Notice of Beneficiary Riehts
Name of Agency:
Name of Program:
Contact information for Program Staff (name, phone number, and e-mail address, if appropriate):
Because this program is supported in whole or in part by direct Federal financial assistance from
the Federal Government, we are required to let you know that:
• We may not discriminate against you on the basis of religion, religious belief, a refusal
to hold a religious belief, or a refusal to attend or participate in a religious practice;
• We may not require you to attend or participate in any explicitly religious activities that
are offered by us and any participation by you in these activities must be purely
voluntary;
• We must separate, in time or location, any privately funded explicitly religious activities
from activities supported by direct Federal financial assistance;
• If you object to the religious character of our organization, we must make reasonable
efforts to identify and refer you to an alternative provider to which you have no such
objection; and
• You may report an organization's violations of these protections, including any denial of
services or benefits, by contacting or filing a written complaint to HUD [or the
intermediary, if applicable].
We must give you this written notice before you enroll in our program or activity, as required by
24 CFR 5.109.
HOPWA PSA CONTRACT -- EXHIBIT "K" — NOTICE OF BENEFICIARY RIGHTS Page 2
NOTICE OF OCCUPANCY RIGHTS UNDER U.S. Department of Housing and Urban Development
THE VIOLENCE AGAINST WOMEN ACT OMB Approval No. 2577-0286
Expires 06/30/2017
EXHIBIT "L" — Notice of Occupancv Rights Under VAWA
[Insert Name of Housing Providerl]
Notice of Occupancy Rights under the Violence Against Women A&
To all Tenants and Applicants
The Violence Against Women Act (VAWA) provides protections for victims of domestic
violence, dating violence, sexual assault, or stalking. VAWA protections are not only available
to women, but are available equally to all individuals regardless of sex, gender identity, or sexual
orientation.3 The U.S. Department of Housing and Urban Development (HUD) is the Federal
agency that oversees that [insert name of program or rental assistance] is in compliance with
VAWA. This notice explains your rights under VAWA. A HUD -approved certification form is
attached to this notice. You can fill out this form to show that you are or have been a victim of
domestic violence, dating violence, sexual assault, or stalking, and that you wish to use your
rights under VAWA."
Protections for Applicants
If you otherwise qualify for assistance under jinsert name of program or rental assistance],
you cannot be denied admission or denied assistance because you are or have been a victim of
domestic violence, dating violence, sexual assault, or stalking.
Protections for Tenants
' The notice uses HP for housing provider but the housing provider should insert its name where HP is used.
HUD's program -specific regulations identify the individual or entity responsible for providing the notice of
occupancy rights.
a Despite the name of this law, VAWA protection is available regardless of sex, gender identity, or sexual
orientation.
' Housing providers cannot discriminate on the basis of any protected characteristic, including race, color, national
origin, religion, sex, familial status, disability, or age. HUD -assisted and HUD -insured housing must be made
available to all otherwise eligible individuals regardless of actual or perceived sexual orientation, gender identity, or
marital status.
Form HUD-5380
(12/2016)
2
If you are receiving assistance under [insert name of program or rental assistance], you may
not be denied assistance, terminated from participation, or be evicted from your rental housing
because you are or have been a victim of domestic violence, dating violence, sexual assault, or
stalking.
Also, if you or an affiliated individual of yours is or has been the victim of domestic violence,
dating violence, sexual assault, or stalking by a member of your household or any guest, you
may not be denied rental assistance or occupancy rights under [insert name of program or
rental assistance] solely on the basis of criminal activity directly relating to that domestic
violence, dating violence, sexual assault, or stalking.
Affiliated individual means your spouse, parent, brother, sister, or child, or a person to whom
you stand in the place of a parent or guardian (for example, the affiliated individual is in your
care, custody, or control); or any individual, tenant, or lawful occupant living in your household.
Removing the Abuser or Perpetrator from the Household
HP may divide (bifurcate) your lease in order to evict the individual or terminate the assistance
of the individual who has engaged in criminal activity (the abuser or perpetrator) directly relating
to domestic violence, dating violence, sexual assault, or stalking.
If HP chooses to remove the abuser or perpetrator, HP may not take away the rights of eligible
tenants to the unit or otherwise punish the remaining tenants. If the evicted abuser or perpetrator
was the sole tenant to have established eligibility for assistance under the program, HP must
allow the tenant who is or has been a victim and other household members to remain in the unit
for a period of time, in order to establish eligibility under the program or under another HUD
housing program covered by VAWA, or, find alternative housing.
Form HUD-5380
(12/2016)
3
In removing the abuser or perpetrator from the household, HP must follow Federal, State, and
local eviction procedures. In order to divide a lease, HP may, but is not required to, ask you for
documentation or certification of the incidences of domestic violence, dating violence, sexual
assault, or stalking.
Moving to Another Unit
Upon your request, HP may permit you to move to another unit, subject to the availability of
other units, and still keep your assistance. In order to approve a request, HP may ask you to
provide documentation that you are requesting to move because of an incidence of domestic
violence, dating violence, sexual assault, or stalking. If the request is a request for emergency
transfer, the housing provider may ask you to submit a written request or fill out a form where
you certify that you meet the criteria for an emergency transfer under VAWA. The criteria are:
(1) You are a victim of domestic violence, dating violence, sexual assault, or
stalking. If your housing provider does not already have documentation that you
are a victim of domestic violence, dating violence, sexual assault, or stalking, your
housing provider may ask you for such documentation, as described in the
documentation section below.
(2) You expressly request the emergency transfer. Your housing provider may
choose to require that you submit a form, or may accept another written or oral
request.
(3) You reasonably believe you are threatened with imminent harm from
further violence if you remain in your current unit. This means you have a
reason to fear that if you do not receive a transfer you would suffer violence in the
very near future.
Form HUD-5380
(12/2016)
0
M
You are a victim of sexual assault and the assault occurred on the premises
during the 90-calendar-day period before you request a transfer. If you are a
victim of sexual assault, then in addition to qualifying for an emergency transfer
because you reasonably believe you are threatened with imminent harm from
further violence if you remain in your unit, you may qualify for an emergency
transfer if the sexual assault occurred on the premises of the property from which
you are seeking your transfer, and that assault happened within the 90-calendar-day
period before you expressly request the transfer.
HP will keep confidential requests for emergency transfers by victims of domestic violence,
dating violence, sexual assault, or stalking, and the location of any move by such victims and
their families.
HP's emergency transfer plan provides further information on emergency transfers, and HP must
make a copy of its emergency transfer plan available to you if you ask to see it.
Documenting You Are or Have Been a Victim of Domestic Violence, Dating Violence,
Sexual Assault or Stalking
HP can, but is not required to, ask you to provide documentation to "certify" that you are or have
been a victim of domestic violence, dating violence, sexual assault, or stalking. Such request
from HP must be in writing, and HP must give you at least 14 business days (Saturdays,
Sundays, and Federal holidays do not count) from the day you receive the request to provide the
documentation. HP may, but does not have to, extend the deadline for the submission of
documentation upon your request.
Form HUD-5380
(12/2016)
You can provide one of the following to HP as documentation. It is your choice which of the
following to submit if HP asks you to provide documentation that you are or have been a victim
of domestic violence, dating violence, sexual assault, or stalking.
• A complete HUD -approved certification form given to you by HP with this notice, that
documents an incident of domestic violence, dating violence, sexual assault, or stalking.
The form will ask for your name, the date, time, and location of the incident of domestic
violence, dating violence, sexual assault, or stalking, and a description of the incident.
The certification form provides for including the name of the abuser or perpetrator if the
name of the abuser or perpetrator is known and is safe to provide.
• A record of a Federal, State, tribal, territorial, or local law enforcement agency, court, or
administrative agency that documents the incident of domestic violence, dating violence,
sexual assault, or stalking. Examples of such records include police reports, protective
orders, and restraining orders, among others.
• A statement, which you must sign, along with the signature of an employee, agent, or
volunteer of a victim service provider, an attorney, a medical professional or a mental
health professional (collectively, "professional") from whom you sought assistance in
addressing domestic violence, dating violence, sexual assault, or stalking, or the effects of
abuse, and with the professional selected by you attesting under penalty of perjury that he
or she believes that the incident or incidents of domestic violence, dating violence, sexual
assault, or stalking are grounds for protection.
• Any other statement or evidence that HP has agreed to accept.
If you fail or refuse to provide one of these documents within the 14 business days, HP does not
have to provide you with the protections contained in this notice.
Form HUD-5380
(12/2016)
0
If HP receives conflicting evidence that an incident of domestic violence, dating violence, sexual
assault, or stalking has been committed (such as certification forms from two or more members
of a household each claiming to be a victim and naming one or more of the other petitioning
household members as the abuser or perpetrator), HP has the right to request that you provide
third -party documentation within thirty 30 calendar days in order to resolve the conflict. If you
fail or refuse to provide third -party documentation where there is conflicting evidence, HP does
not have to provide you with the protections contained in this notice.
Confidentiality
HP must keep confidential any information you provide related to the exercise of your rights
under VAWA, including the fact that you are exercising your rights under VAWA.
HP must not allow any individual administering assistance or other services on behalf of HP (for
example, employees and contractors) to have access to confidential information unless for
reasons that specifically call for these individuals to have access to this information under
applicable Federal, State, or local law.
HP must not enter your information into any shared database or disclose your information to any
other entity or individual. HP, however, may disclose the information provided if-
0 You give written permission to HP to release the information on a time limited basis.
• HP needs to use the information in an eviction or termination proceeding, such as to evict
your abuser or perpetrator or terminate your abuser or perpetrator from assistance under
this program.
• A law requires HP or your landlord to release the information.
Form HUD-5380
(12/2016)
VAWA does not limit HP's duty to honor court orders about access to or control of the property.
This includes orders issued to protect a victim and orders dividing property among household
members in cases where a family breaks up.
Reasons a Tenant Eligible for Occupancy Rights under VAWA May Be Evicted or
Assistance May Be Terminated
You can be evicted and your assistance can be terminated for serious or repeated lease violations
that are not related to domestic violence, dating violence, sexual assault, or stalking committed
against you. However, HP cannot hold tenants who have been victims of domestic violence,
dating violence, sexual assault, or stalking to a more demanding set of rules than it applies to
tenants who have not been victims of domestic violence, dating violence, sexual assault, or
stalking.
The protections described in this notice might not apply, and you could be evicted and your
assistance terminated, if HP can demonstrate that not evicting you or terminating your assistance
would present a real physical danger that:
1) Would occur within an immediate time frame, and
2) Could result in death or serious bodily harm to other tenants or those who work on the
property.
If HP can demonstrate the above, HP should only terminate your assistance or evict you if there
are no other actions that could be taken to reduce or eliminate the threat.
Other Laws
VAWA does not replace any Federal, State, or local law that provides greater protection for
victims of domestic violence, dating violence, sexual assault, or stalking. You may be entitled to
Form HUD-5380
(12/2016)
additional housing protections for victims of domestic violence, dating violence, sexual assault,
or stalking under other Federal laws, as well as under State and local laws.
Non -Compliance with The Requirements of This Notice
You may report a covered housing provider's violations of these rights and seek additional
assistance, if needed, by contacting or filing a complaint with [insert contact information for
any intermediary, if applicable] or [insert HUD field office].
For Additional Information
You may view a copy of HUD's final VAWA rule at [insert Federal Register link].
Additionally, HP must make a copy of HUD's VAWA regulations available to you if you ask to
see them.
For questions regarding VAWA, please contact [insert name of program or rental assistance
contact information able to answer questions on VAWA].
For help regarding an abusive relationship, you may call the National Domestic Violence Hotline
at 1-800-799-7233 or, for persons with hearing impairments, 1-800-787-3224 (TTY). You may
also contact [Insert contact information for relevant local organizations].
For tenants who are or have been victims of stalking seeking help may visit the National Center
for Victims of Crime's Stalking Resource Center at https://www.victimsofcrime.org/our-
programs/stalking-resource-center.
For help regarding sexual assault, you may contact [Insert contact information for relevant
organizations]
Victims of stalking seeking help may contact [Insert contact information for relevant
organizations].
Attachment: Certification form HUD-5382 [form approved for this program to be included]
Form HUD-5380
(12/2016)
EXHIBIT "M" — Emergency Transfer Request Form
CERTIFICATION OF U.S. Department of Housing OMB Approval No. 2577-0286
DOMESTIC VIOLENCE, and Urban Development Exp. 06/30/2017
DATING VIOLENCE,
SEXUAL ASSAULT, OR STALKING,
AND ALTERNATE DOCUMENTATION
Purpose of Form: The Violence Against Women Act ("VAWA") protects applicants, tenants, and
program participants in certain HUD programs from being evicted, denied housing assistance, or
terminated from housing assistance based on acts of domestic violence, dating violence, sexual assault, or
stalking against them. Despite the name of this law, VAWA protection is available to victims of domestic
violence, dating violence, sexual assault, and stalking, regardless of sex, gender identity, or sexual
orientation.
Use of This Optional Form: If you are seeking VAWA protections from your housing provider, your
housing provider may give you a written request that asks you to submit documentation about the incident
or incidents of domestic violence, dating violence, sexual assault, or stalking.
In response to this request, you or someone on your behalf may complete this optional form and submit it
to your housing provider, or you may submit one of the following types of third -party documentation:
(1) A document signed by you and an employee, agent, or volunteer of a victim service provider, an
attorney, or medical professional, or a mental health professional (collectively, "professional") from
whom you have sought assistance relating to domestic violence, dating violence, sexual assault, or
stalking, or the effects of abuse. The document must specify, under penalty of perjury, that the
professional believes the incident or incidents of domestic violence, dating violence, sexual assault, or
stalking occurred and meet the definition of "domestic violence," "dating violence," "sexual assault," or
"stalking" in HUD's regulations at 24 CFR 5.2003.
(2) A record of a Federal, State, tribal, territorial or local law enforcement agency, court, or
administrative agency; or
(3) At the discretion of the housing provider, a statement or other evidence provided by the applicant or
tenant.
Submission of Documentation: The time period to submit documentation is 14 business days from the
date that you receive a written request from your housing provider asking that you provide documentation
of the occurrence of domestic violence, dating violence, sexual assault, or stalking. Your housing
provider may, but is not required to, extend the time period to submit the documentation, if you request an
extension of the time period. If the requested information is not received within 14 business days of when
you received the request for the documentation, or any extension of the date provided by your housing
provider, your housing provider does not need to grant you any of the VAWA protections. Distribution or
issuance of this form does not serve as a written request for certification.
Confidentiality: All information provided to your housing provider concerning the incident(s) of
domestic violence, dating violence, sexual assault, or stalking shall be kept confidential and such details
shall not be entered into any shared database. Employees of your housing provider are not to have access
to these details unless to grant or deny VAWA protections to you, and such employees may not disclose
this information to any other entity or individual, except to the extent that disclosure is: (i) consented to
Form HUD-5382
(06/2017)
2
by you in writing in a time -limited release; (ii) required for use in an eviction proceeding or hearing
regarding termination of assistance; or (iii) otherwise required by applicable law.
TO BE COMPLETED BY OR ON BEHALF OF THE VICTIM OF DOMESTIC VIOLENCE,
DATING VIOLENCE, SEXUAL ASSAULT, OR STALKING
1. Date the written request is received by victim:
2. Name of victim:
3. Your name (if different from victim's):
4. Name(s) of other family member(s) listed on the lease:
5. Residence of victim:
6. Name of the accused perpetrator (if known and can be safely disclosed):
7. Relationship of the accused perpetrator to the victim:
8. Date(s) and times(s) of incident(s) (if known):
10. Location of incident(s):
In your own words, briefly describe the incident(s):
This is to certify that the information provided on this form is true and correct to the best of my knowledge
and recollection, and that the individual named above in Item 2 is or has been a victim of domestic violence,
dating violence, sexual assault, or stalking. I acknowledge that submission of false information could
jeopardize program eligibility and could be the basis for denial of admission, termination of assistance, or
eviction.
Signature Signed on (Date)
Public Reporting Burden: The public reporting burden for this collection of information is estimated to
average 1 hour per response. This includes the time for collecting, reviewing, and reporting the data. The
information provided is to be used by the housing provider to request certification that the applicant or
tenant is a victim of domestic violence, dating violence, sexual assault, or stalking. The information is
subject to the confidentiality requirements of VAWA. This agency may not collect this information, and
you are not required to complete this form, unless it displays a currently valid Office of Management and
Budget control number.
Form HUD-5382
(06/2017)
City of Fort Worth, Texas
Mayor and Council Communication
DATE: 08/08/23
M&C FILE NUMBER: M&C 23-0631
LOG NAME: 19NS 2023-2027 CONSOLIDATED PLAN AND 2023-2024 ACTION PLAN
SUBJECT
(ALL) Conduct Public Hearing and Approve the City of Fort Worth's 2023-2027 Consolidated Plan
Priorities and Goals and 2023-2024 Annual Action Plan for the Use of Federal Grant Funds in the
Amount of $13,452,621.00 to be Awarded by the United States Department of Housing and Urban
Development from the Community Development Block Grant, HOME Investment Partnerships
Program, Emergency Solutions Grant, and Housing Opportunities for Persons with AIDS Program,
Authorize Collection and Use of Program Income, Authorize Execution of Related Contracts, Adopt
Appropriation Ordinance, and Authorize Waiver of Indirect Costs
(PUBLIC HEARING - a. Report of City Staff Sharon Burkley; b. Public Comment; c. Council Action:
Close Public Hearing and Act on M&C)
RECOMMENDATION:
It is recommended that City Council:
1. Conduct a public hearing to allow citizen input and consideration of the City's 2023-2027
Consolidated Plan Priorities and Goals and 2023-2024 Annual Action Plan for use of federal
grant funds to be awarded by the United States Department of Housing and Urban
Development in the amount of $13,552,621.00 from the Community Development Block Grant,
HOME Investment Partnerships Program, Emergency Solutions Grant, and Housing
Opportunities for Persons with AIDS grant programs, and for the use of program income from
activities using prior years' federal grant funds;
2. Approve the City's 2023-2027 Consolidated Plan and 2023-2024 Annual Action Plan for
submission to the United States Department of Housing and Urban Development, including
allocations of grant funds to particular programs and activities as detailed below;
3. Authorize an increase in the City's Priority Repair Program contract authority by $500,000.00
annually for a total annual amount of $2,500,000.00 for the next five years (Fiscal Years 2023-
2027) contract authority of $46,858,546.53 to reflect the increased annual funding allocation
from $2,000,000.00 to $2,500,000.00.
4. Authorize the collection and use of an estimated $50,000.00 of program income which is
expected to result from activities using prior years' Community Development Block Grant funds
for the City's Priority Repair Program;
5. Authorize the collection and use of an estimated $50,000.00 of program income which is
expected to result from activities using prior years' HOME Investment Partnerships Program
grant funds for the City's Homebuyer Assistance Program, and authorize the use of 10 percent
of the program income for administrative costs;
6. Authorize the City Manager or his designee to execute contracts for one-year terms with the
agencies listed in Tables 1,2, and 3 below for Program Year 2023-2024 for Community
Development Block Grant, Emergency Solutions Grant, and Housing Opportunities for Persons
with AIDS grant funds, contingent upon receipt of funding, and satisfactory completion of all
federal regulatory requirements;
7. Authorize the City Manager or his designees to extend the contracts for up to one year if an
agency or department requests an extension and such extension is necessary for completion
of the program, or to amend the contracts if necessary to achieve program goals provided any
amendment is within the scope of the program and in compliance with City policies and all
applicable laws and regulations governing the use of federal grant funds;
8. Adopt the attached appropriation ordinance increasing estimated receipts and appropriations
in the Grants Operating Federal Fund in the total amount of $13,452,621.00 consisting of
$6,994,785.00 in Community Development Block Grant funds, $3,271,119.00 in HO
Investment Partnerships Program funds, $610,543.00 in Emergency Solutions Grant funds,
and $2,576,174.00 in Housing Opportunities for Persons with AIDS grant funds, plus
estimated program income in the amount of $100,000.00, all subject to receipt of such funds;
and
9. Authorize a waiver of the Neighborhood Services Department indirect cost rate of 28.10%,
estimated total of $393,106.92.
DISCUSSION:
The City of Fort Worth's (City's) 2023-2027 Consolidated Plan assesses community and affordable
housing needs and sets strategic priorities and goals for use of federal grants funds from the United
States Department of Housing and Urban Development (HUD) for a five-year period. These
priorities and goals are to be addressed with Annual Action Plans that summarize the major housing
and community development activities and proposed expenditures for each of the five years.
These priorities and goals were developed to be consistent with strategies and initiatives previously
adopted by the City Council, as well as through an assessment of community needs. This included
Citywide public meetings conducted by JQuad Planning Group, the consultant contracted to prepare
the Consolidated Plan in collaboration with the Neighborhood Services Department staff. The
recommended Consolidated Plan priorities and goals for use of HUD grant funds over the next five
years are summarized below.
PRIORITY NEED
GOAL
Promote Affordable
Housing for Renters and
Increase neighborhood stability through homeownership assistance; Fair
Owners
Housing efforts, and supportive services for renters and owners
Housing Preservation
Preserve and expand the supply of quality affordable housing throughout
and Rehabilitation
the City
Neighborhood
Improvement and
Enhance neighborhood development and revitalization throughout the City
Revitalization
Economic Empowerment Support programs and services providing employment training and career
and Financial Resilience
11readiness programs that promote self-sufficiency and household stability
Children and Youth
Support programs and services to prepare children and youth for success
Services
through educational, mentoring, training and related programs
Support programs and services for older adults to access resources
Aging In Place
needed to age in their homes, while maintaining both their independence
and quality of life
Accessibility
Improve accessibility in public facilities and housing, including architectural
Improvements
barrier removal
Homelessness
IlProvide housing and support services for persons experiencing and at -risk
Prevention and Special lof experiencing homelessness; support efforts to achieve permanent
Needs Support 1housing
Healthy Living and Support programs and services to improve the mental and physical health
Wellness of low -to moderate -income Fort Worth families
The City's 2023-2024 Annual Action Plan summarizes the major housing and community
development activities and proposed expenditures for the program year beginning October 1, 2023
and ending September 30, 2024 for use of federal grant funds totaling $13,452,621.00 from the
United States Department of Housing and Urban Development (HUD) from the Community
Development Block Grant (CDBG), HOME Investment Partnerships Program (HOME), Emergency
Solutions Grant (ESG), and Housing Opportunities for Persons with AIDS (HOPWA) grant programs.
It also summarizes the use of program income resulting from activities using prior years' CDBG and
HOME funds, the primary purpose of which is to benefit low -and moderate -income persons in Fort
Worth. ESG funds primarily benefit persons experiencing homelessness, and HOPWA funds
primarily benefit low -and moderate -income persons with HIV/AIDS.
A Request for Proposals from social service agencies and nonprofit organizations seeking grant
funding was published on February 1, 2023. All proposals were received on March 15, 2023. Staff
reviewed all proposals and developed recommendations for the allocation of estimated funding from
HUD based on the capacity of applicant organizations, grant experience, fiscal stability, and
compliance with applicable federal regulations. One public hearing was held on April 12, 2023 to
provide citizens the opportunity to participate in the development of the Annual Action Plan.
Recommendations for award amounts were considered and adopted by the Community
Development Council on May 10, 2023. These funding recommendations were presented in City
Council Work Session on August 1, 2023.
A 30-day public comment period was held from June 30, 2023 to July 31, 2023. Notice of this public
comment period was published in the Fort Worth Star -Telegram on June 29, 2023; in the Cleburne
Times Review on July 6; in the Weatherford Democrat on July 8; and in La Vida News on July 13.
Any comments received are maintained by the Neighborhood Services Department in accordance
with federal regulations. The City held two public hearings as a part of the HUD required citizen
participation process. The first public hearing was held by staff on July 12, 2023, and the second
public hearing is scheduled for the City Council on August 8, 2023.
A summary of staff's final funding recommendations is provided below in Tables 1,2, and 3. A
Powerpoint presentation listing funding recommendations is also attached. The 2023-2024 Annual
Action Plan will be submitted to HUD by August 15, 2023.
Indirect costs totaling approximately $393,106.92 could be charged to these grants, as the
Neighborhood Services Department indirect cost rate is 28.10% in the City's most recent Cost
Allocation Plan. A waiver of these costs is requested to allow allocation of these funds to further
support the programs and services to assist low -to -moderate income citizens.
Mayor & Council Communication (M&C) 22-0569 dated August 9, 2022 increased the annual
funding amount of the City's Priority Repair Program (PRP) from $1,100,000.00 to $2,000,000.00.
Approval of this M&C authorizes an additional increase of annual funding from $2,000,000.00 to
$2,500,000.00. This will require an increase in the expenditure authority for the PRP and the
contracting authority for PRP agreements, resulting in an annual increase of $500,000.00. A total
five year (Fiscal Years 2023-2027) contract authority of $46,858,546.53 for PRP is necessary to
facilitate the increase in funding from CDBG.
COMMUNITY DEVELOPMENT BLOCK GRANT
For Program Year 2023-2024, it is recommended that the amount of $6,994,785.00 in CDBG funds
and an estimated amount of $50,000.00 in CDBG program income totaling $7,044,785.00 be
allocated as follows:
• Public Service Agencies - $1,049,218.00: Includes social services for low- and moderate -
income persons, persons with disabilities, and disadvantaged persons
• Housing Programs - $3,910,000.00: Includes funding for the City's Priority Repair Program,
Cowtown Brush -Up, homebuyer and housing services, accessibility modifications for seniors
and persons with disabilities, and related project delivery costs for these programs
• Major Projects - $636,610.00- Includes for multifamily rental rehabilitation
• Administration - $1,398,957.00: Includes costs for administering the CDBG grant, including
allocations for the Financial Management Services Department
• Estimated Program Income - $50,000.00: Includes up to $50,000.00 in funding for the City's
Priority Repair Program. Any CDBG program income over the estimated amount not used for
the Priority Repair Program will be allocated to priority activities in the City's Consolidated
Plan, subject to the City Council approval.
HOME INVESTMENT PARTNERSHIPS PROGRAM
For Program Year 2023-2024, it is recommended that the amount of $3,271,119.00 in HOME funds
and an estimated amount of $50,000.00 in HOME program income totaling $3,321,119.00 be
allocated as follows:
• Homebuyer Assistance Program - $408,339.25: Includes funding for down payment and
closing cost assistance for low- and moderate -income homebuyers
• Community Housing Development Organization - $490,667.85: HUD requires that a minimum
of 15 percent of HOME funds be allocated to Community Housing Development Organizations
(CHDOs) for affordable housing projects. These funds will be used by Housing Channel for
multifamily housing development in southeast Fort Worth. All housing developed with these
funds will be sold to homebuyers making at or below 80 percent of area median income (AMI),
set by HUD.
• Community Housing Development Organization Operating - $45,000.00:
• Major Projects - $2,000,000.00: Includes funds ($1,000,000.00) allocated to the affordable
housing project to be developed by Fort Worth Housing Solutions (FWHS) as a part of its
Choice Neighborhood Initiative (CNI) grant and funds ($1,000,000.00) allocated to the
multifamily housing project, Columbia Renaissance - Phase III
• Administration - $327,111.90: Includes costs for administering the HOME grant
• Estimated Program Income - $50,000.00: Includes funding for the Homebuyer Assistance
Program and HOME grant administrative costs. HUD allows the City to use 10 percent of any
HOME program income towards the cost of administering the HOME grant. HOME program
income over the estimated amount not used for the Homebuyer Assistance Program will be
allocated to priority activities in the City's Consolidated Plan, subject to City Council approval.
HOUSING OPPORTUNITIES FOR PERSONS WITH AIDS
For Program Year 2023-2024, it is recommended that the amount of $2,576,174.00 in HOPWA
funds be allocated as follows:
Public Service Agencies - $1,729,850.00
Neighborhood Services Department - $769,039.00
Administration - $77,285.00
EMERGENCY SOLUTIONS GRANT
For Program Year 2023-2024, it is recommended that the amount of $610,543.00 in ESG funds to
be allocated as follows:
• Public Service Agencies - $564,752.00
• Administration - $45,791.00
CONTRACT RECOMMENDATIONS
The Community Development Council and Neighborhood Services Department staff recommend
that contracts be executed with the public service and CDBG subrecipient agencies for the amounts
shown in the following tables:
Community Development Block Grant Contracts
AGENCY
�AB Christian Learning Center
Boys & Girls Clubs of Greater
Tarrant County, Inc.
Camp Fire First Texas
Cancer Care Services
Easter Seals North Texas, Inc
Girls Incorporated of Tarrant
County
Guardianship Services, Inc.
Housing Channel
Junior Achievement of the
Chisholm Trail, Inc.
Maroon 9 Community
Enrichment Organization
TABLE 1: CDBG AGENCIES
CONSOLIDATED
PLAN GOAL
Children and Youth
Services
Children and Youth
Services
Children and Youth
Services
Healthy Living and
Wellness
Economic
Empowerment and
Financial Resilience
Children and Youth
Services
Aging In Place
Promote Affordable
Housing for Renters
and Owners
lChildren and Youth
Services
Children and Youth
Services
Meals -On -Wheels, Inc. of Tarrant Aging In Place
County
NPower Inc.
The Ladder Alliance
The Women's Center of Tarrant
County, Inc.
Economic
Empowerment and
Financial Resilience
Economic
Empowerment and
Financial Resilience
Economic
Empowerment and
Financial Resilience
PROGRAM
Out of School Time
Program
Youth Development
at Eastside Branch
Teens In Action
k
ancer Care
ervices
AMOUNT
$78,218.00
$70,000.00
$50,000.00
$50,000.00
Employment
$60,000.00
Services
Leadership $100,000.00
Program
Money Smart+ 11 $100,000.00
Housing Counseling
& Education
lCradle to Career
Initiative
Maroon 9 Teen
Enrichment
Program
Nutrition Program
Tech Fundamentals
Workforce Training
Program
Tarrant County
Workforce
Development
$111,000.00
$25,000.00
$25,000.00
$75,000.00
$25,000.00
':1 111 11
Employment
Solutions $75,000.00
United Community Centers, Inc. Children and Youth Holistic Educational
Services Literacy Program
CDBG Public Services Agencies Total
$125,000.00
$1,049,218.00
Rehabilitation, Education and Accessibility
Advocacy for Citizens with Improvements Project Ramp $165,000.00
Handicaps dba REACH, Inc.
Fort Worth Area Habitat for
Humanity, Inc. DBA Trinity Habitat Housing Preservation
for Humanity and Rehabilitation
CDBG Subrecipient Agencies Total
TOTAL CDBG CONTRACTS
Cowtown Brush Up
Housing Opportunities for Persons with AIDS Contracts
TABLE 2: HOPWA AGENCIES
$455,000.00
$620,000.00
$1,669,218.00
AGENCY PROGRAM AMOUNT
AIDS Outreach Administration, Support Services, Short -Term Rent,
Center, Inc. Mortgage, and Utility Assistance (STRMU), Tenant -Based $429,850.00
Rental Assistance
Tarrant County Administration, Facility -Based Operations, Supportive
Samaritan Services, Tenant -Based Rental Assistance (TBRA) $1,300,000.00
Housing, Inc.
TOTAL HOPWA CONTRACTS $1,729,850.00
Emergency Solutions Grants
TABLE 3: ESG AGENCIES
AGENCY
The Presbyterian Night Shelter of Tarrant
County, Inc.
Lighthouse for the Homeless dba True Worth
Place
The Salvation Army
Center for Transforming Lives
SafeHaven of Tarrant County
TOTAL ESG CONTRACTS
PROGRAM J AMOUNT
Shelter Operations/Services $116,635.00
Day Shelter
Operations/Services $158,400.00
Homelessness Prevention J$150,000.00
Rapid Re -Housing 11 $75,901.00
Shelter Operations/Services J $63,816.00
11$564,752.00
All figures have been rounded to the nearest dollar for presentation purposes. These programs are
available in ALL COUNCIL DISTRICTS.
Each of these grants is an entitlement grant rather than a competitive grant received from the United
States Department of Housing and Urban Development (HUD). Entitlement grants provide funds to
agencies based on a formula, prescribed in legislation or regulation, rather than based on review.
These specific grants are allocated to the City of Fort Worth based on population size and per capita
income each year. The grants have been consistently awarded to the City since 1974 with the
inception of the Community Development Block Grant (CDBG) through the Housing and Community
Development Act of 1974. The Emergency Shelter (renamed Solutions) Grant (ESG) was authorized
in 1987 through the McKinney-Vento Homelessness Assistance Act. The HOME Investment
Partnerships Program (HOME) and the Housing Opportunities for Persons with AIDS (HOPWA)
Program were authorized in 1990 through the Cranston -Gonzales National Affordable Housing Act of
1990. With these grants, administrative and program delivery allocations support approximately 72
FTE positions in the Neighborhood Services Department, which is funded nearly 70% with various
grants including these entitlement grants.
Positions funded with HUD Entitlement grants are subject to grant availability. In the event of a grant
award being decreased or eliminated, Neighborhood Services Department would review programs
and services funded by the grants and determine a level of service and staffing that aligns with the
available funding. Alternatives to consider may include staff and program reductions or eliminations.
FISCAL INFORMATION / CERTIFICATION:
The Director of Finance certifies that upon approval of the above recommendations and adoption of
the attached appropriation ordinance, funds will be available in the current operating budget, as
appropriated, of the Grants Operating Federal Fund. The Neighborhood Services Department (and
Financial Management Services) will be responsible for the collection and deposit of funds due to
the City. Prior to an expenditure being incurred, the Neighborhood Services Department has the
responsibility to validate the availability of funds. This is a reimbursement grant.
Submitted for Citv Manaaer's Office bv:
Oriainatina Business Unit Head:
Additional Information Contact
Fernando Costa 6122
Victor Turner 8187
Sharon Burkley 5785
Rhonda Hinz 2573