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E},HIBIT A <br />REPORT FORM E <br />SUPPORTIVE SERVICES ONLY <br />Activity Name: <br />Activity Location: <br />Persons Wrth HIVIAIDS <br />Other Persons in Family Unit <br />Total <br />Receiving Supportive Svcs <br />w/ Housing Assistance <br />Receiving Supportive Svcs <br />Ony <br />Supportive Services <br />1. Outreach <br />2. Case ManagemenU Advocacy/Access to Benefits Svcs <br />3. L'rfe Management (outside of Case Management <br />4. Nutritional ServiceslMeals <br />5. Adult Day care and Personal Assistance <br />6. Child Care and other Children's Services <br />7. Education <br />S. Employment Assistance <br />9. Alcohd and Drub Abuse Services <br />10. Mental Health Services <br />11. Health/MediceUlntens'rve Care Services <br />12. Permanent Housing Placement <br />13. Emergency Housing <br />14. Transitional Shelter <br />15. Other <br />TOTAL <br />• Number of Jobs that Result from # 7 & 8 <br />HOPWA EXPENDITURES (in ddlars) <br />Allocated HOPWA Funds: <br />Allocated HOPWA Program Income: <br />Total HOPWA funds for Project: <br />Total HOPWA Expended to date: <br />Balance HOPWA Funds to date: <br />Source of Non-HOPWA Funds <br />Expended <br />S <br />S <br />a <br />; <br />; <br />E <br />S <br />; <br /># of Persons Served <br />E <br /> <br />Total Available <br />; <br />Expended To Date <br /> <br />Total Non-HOPWA Funds: <br />HOF'WA Report Form E 6 of 7 11/t?'04 <br />