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EXHIBIT A <br />REPORT FORM A <br />FACILITY BASED HOUSING <br />(Housing Acquisition, Construction or Rehab) <br />FACILITY NAME: <br />FACILITY TYPE: <br />NUMBER OF UNfrS BY FACILITY TYPE <br />SRO 0 Bdnn 1 8drms 2 Bdnns 3 Bdrnis 4 Bdrms S+~Bdn»s <br />Date of ClosinglLease Execution: <br />Date ConstructionlRehab Started: <br />Completed: <br />Date Operations Staff Hired: <br />Date Residents Began to Occupy: <br />HOPWA EXPENDITURES fin dollars) <br />Acquisition: <br />Rehab/Conversion/Repair. <br />Lease: <br />New Construction: <br />Operating Costs: <br />Technical Assistance: <br />Rental Assistance: <br />Other: <br />Other. <br />Is the site owned by a public entity? <br />Is this activity "substantial" rehab? <br />Available HOPWA Funds <br />S <br />s <br />s <br />s <br />S <br />S <br />S <br />TOTAL: ~ <br />QYes ^No <br />QYes ^No <br />Allocated HOPWA Funds: S <br />Allocated HOPWA Program Income: + S <br />Total HOPWA funds for Project: = ~ <br />Total HOPWA Expended to date: - ~ <br />Balance HOPWA Funds io date: = ~ <br />Source of Non-HOPWA Funds <br />Expended To pate Total Available <br />S ~ <br />~ ~ <br />Total Non-HOPWA Funds: ~ ~ <br />SUfiMI,,Y P;EIAEN ~Rt=POft~ <br />FtOPWARepori corm A 2 of 7 <br />11/1J04 <br />