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<br />EXHIBIT A <br /> <br />REPORT FORM C <br />SCATTERED SITE HOUSING ACTIVITY <br />(Tenant Based Rental Assistance, Emergency Housing/Utility Assistance) <br /> <br />Activity Name: <br />Activity Location: <br /> <br />Date Payments Began: <br /> <br />Number of Units Assisted by Payment Type <br />SRO 0 Bdrm 1 Bdrm 2 Bdrms 3 Bdrms 4 Bdrms 5+ Bdrms <br /> <br />Tenant-Based Rent <br />Rent, Mortgage, Utilities <br /> <br />Expenditures By Type: Tenant-Based Rent:$ <br /> <br />Rent, Mortgage, Utilities: $ <br /> <br />Total Families Assisted with Housing Assistance: <br /> <br />Program Departure Counts <br /> <br />Number of Months <br />Voluntary: <br />Nonpayment of rent: <br />Supportive Service noncompliance: <br />Unknown: <br />Criminal: <br /> <br /><3 <br /> <br />3-6 <br /> <br />7-12 <br /> <br />>12 <br /> <br />Death: <br /> <br />Other <br /> <br />HOPWA EXPENDITURES (in dollars) <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 />$ <br />+$ <br />=$ <br />-$ <br />=$ <br /> <br />Source of Non-HOPWA Funds <br /> <br />Total Available <br /> <br />Expended To Date <br />$ <br />$ <br />$ <br />$ <br /> <br />Total Non-HOPWA Funds: <br /> <br />$ <br />$ <br />$ <br />$ <br /> <br />SUBMITSUPPLEI\'lENTAL REPORT FORM <br /> <br />HOPWA Report Form C <br /> <br />4 of 7 <br /> <br />11112/04 <br />