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<br />EXHIBIT A <br /> <br />REPORT FORM B <br />FACILITY-BASED NON-HOUSING <br />(Property Acquisition, Construction or Rehab) <br /> <br />Activity Name: <br />Facility Type: <br /> <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 /> <br />Date of Closing/Lease Execution: <br />Date Construction/Rehab Started: <br />Date Construction/Rehab Completed: <br />Date Operations Staff Hired: <br />Date Support Services Started: <br /> <br />HOPWA Site Expenditures (in dollars) <br />Acquisition: <br />Reha b/Conversion/Repair: <br />Lease: <br />Operating Costs: <br />Other: <br />Other: <br /> <br />Is the site owned by a public entity? <br />Is this activity "substantial" rehab? <br /> <br />Source Of Non-HOPWA Funds <br /> <br />Total Non-HOPWA Funds: <br /> <br />TOTAL: <br /> <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br /> <br />DYes <br />DYes <br /> <br />DNo <br />DNo <br /> <br />Total Available <br />$ <br />$ <br />$ <br />$ <br /> <br />Expended To Date <br />$ <br />$ <br />$ <br />$ <br /> <br />SUBMIl'.$;UI1PLEMEl'li\:AL; RE;!;>ORTf,QRM <br /> <br />HOPWA Report Form B <br /> <br />3 of 7 <br /> <br />11/12/04 <br />