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EXHIBIT A <br />REPORT FORM C <br />SCATTERED SITE HOUSING ACTIVITY ' <br />(Tenant Based Rental Assistance, Emergency HousinglUtlity Assistance) <br />Activity Name• - <br />Activity Location: <br />Date Payments Began: <br />Number of Units Assisted by Payment Type <br />SRO 0 Bdrm 1 Bdrm 2 Bdrms 3 Bdmu 4 Bdrms . 5+ Bdrms . <br />Tenant-Based Rent <br />Rent, Mortgage, Utilities <br />Expenditures By Type: Tenant-Based Rents Rent, Mortgage, Utilities: S <br />Total Families Assisted with Housing Assistance: <br />Program Departure Counts <br />Number of Months <3 <br />Voluntary. <br />Nonpayment of rent: <br />Supportive Service noncompliance: <br />Unknown: <br />Criminal: <br />Death: <br />Other <br />HOPWA EXPENDITURES ('in doNars) - <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 />3-6 7-12 >12 <br />S <br />+s <br />=S <br />-s <br />=S <br />Total Available <br />Expended To Date <br />SIT~LE E -N~~EPO : ~ TFORM <br />Hnawe~o,,,,,.c,.,.,,r 4 OL' 7 11!12/04 <br />