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<br />E) HIBIT A <br />REPORT FORM E <br />SUPPORTIVE SERVICES ONLY <br /> <br />Activity Name: <br /> <br />Activity Location: <br /> <br />Receiving Supportive Svcs <br />w/ Housing Assistance <br /> <br />Persons With HIV/AIDS <br />Other Persons in Family Unit <br />Total <br /> <br />Receiving Supportive Svcs <br />Only <br /> <br />Supportive Services <br />1. Outreach <br />2. Case ManagemenU Advocacy/Access to Benefits Svcs <br />3. Life Management (outside of Case Management <br />4. Nutritional Services/Meals <br />5. Adult Day care and Personal Assistance <br />6. Child Care and other Children's Services <br />7. Education <br />8. Em ployment Assistance <br />9. Alcohol and Drub Abuse Services <br />10. Mental Health Services <br />11. Health/Medical/Intensive Care Services <br />12. Permanent Housing Placement <br />13. Emergency Housing <br />14. Transitional Shelter <br />15. Other <br /> <br />TOTAL <br /> <br />. Number of Jobs that Result from # 7 & 8 <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 />Source of Non-HOPWA Funds <br /> <br />Total Available <br /> <br />$ <br />$ <br />$ <br />$ <br /> <br /># of Persons Served <br /> <br />$ Expended <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br /> <br />$ <br />+$ <br />=$ <br />-$ <br />=$ <br /> <br />Total Non-HOPWA Funds: <br /> <br />HOPWA Report Form E <br /> <br />6 of 7 <br /> <br />Expended To Date <br />$ <br />$ <br />$ <br />$ <br /> <br />11/12/04 <br />