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EXHIBIT A <br />REPORT FORM B <br />FACILITY-BASED NON-HOUSING <br />(Property Acquisition, Construction or Rehab) <br />Activity Name: <br />Facility Type: <br />Date of ClosinglLease Execution: <br />Date ConstructionlRehab Started: <br />Date ConstructionlRehab Completed: <br />Date Operations Staff Hired: <br />Date Support Services Started: <br />HOPWA Site Expenditures (~n donars) <br />Acquisition: <br />Rehab/Conversion/Repair: <br />Lease: <br />Operating Costs: <br />Other. <br />Other: <br />TOTAL: <br />Is the site owned by a public entity? QYes <br />Is this activity "substantial" rehab? QYes <br />Available HOPWA Funds <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 />Total Non-HOPWA Funds: <br />^No <br />^No <br />S <br />+~ <br />=S <br />-S <br />=S <br />Total Available Expended To Date <br />S S <br />~ ~ S <br />~ ~ <br /> <br />SUB~I - . ~E~ ~ _ , E ::OE~T ~012f3t <br />3 of 7 <br />S <br />S <br />S <br />S <br />S <br />HOPWA Pzport Form 'S ~ 1!1 ~/oa <br />