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<br />EXHIBIT A <br /> <br />REPORT FORM A <br />FACILITY BASED HOUSING <br />(Housing Acquisition, Construction or Rehab) <br /> <br />FACILITY NAME: <br />FACILITY TYPE: <br /> <br />NUMBER OF UNITS BY FACILITY TYPE <br /> <br />SRO <br /> <br />o Bdrm <br /> <br />1 Bdrms <br /> <br />2 Bdrms <br /> <br />3 Bdrms <br /> <br />4 Bdrms <br /> <br />5+ Bdrms <br /> <br />Date of Closing/Lease Execution: <br />Date Construction/Rehab Started: <br />Completed: <br />Date Operations Staff Hired: <br />Date Residents Began to Occupy: <br /> <br />HOPWA EXPENDITURES (in 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 /> <br />TOTAL: <br /> <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br /> <br />Is the site owned by a public entity? <br />Is this activity "substantial" rehab? <br /> <br />DYes <br />DYes <br /> <br />DNo <br />DNo <br /> <br />Available HOPWA Funds <br />Ailocated HOPWA Funds: <br />Ailocated HOPWA Program Income: <br />Total HOPWA funds for Project: <br />Total HOPWA Expended to date: <br />Balance HOPWA Funds to date: <br /> <br />$ <br />+$ <br />=$ <br />-$ <br />=$ <br /> <br />Source of Non.HOPWA Funds <br /> <br />Expended To Date <br />$ <br />$ <br /> <br />$ <br />Total Non.HOPWA Funds: $ <br /> <br />Total Available <br /> <br />$ <br />$ <br />$ <br />$ <br /> <br />HOPWA Report Form A <br /> <br />SUBMIT ~UPpLEMENr~ REPORT FORM <br />2 of 7 <br /> <br />11/12/04 <br />