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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 o Bdrm 1 Bdrms 2 Bdrms 3 Bdrms 4 Bdrms 5+ Bdrms <br /> <br />Date of Closing/Lease Execution: <br /> <br />Date Construction/Rehab Started: <br /> <br />Date Construction/Rehab Completed: <br /> <br />Date Operations Staff Hired: <br /> <br />Date Residents Began to Occupy: <br /> <br />HOPWA EXPENDITURES (in dollars) <br /> <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 />Ai/ocated HOPWA Funds: <br /> <br />$ <br /> <br />Ai/ocated HOPWA Program Income: <br /> <br />+$ <br /> <br />Total HOPWA funds for Project: <br /> <br />=$ <br />-$ <br />=$ <br /> <br />Total HOPWA Expended to date: <br /> <br />Balance HOPWA Funds to date: <br /> <br />Source of Non-HOPWA Funds: <br />(Including In.Kind Contributions) <br /> <br />Expended To Date: <br /> <br />Total Available: <br /> <br />$ <br />$ <br />$ <br />Total Non-HOPWA Funds: $ <br /> <br />$ <br />$ <br />$ <br />$ <br /> <br />~W!';lNljf.sl!!\,r;alilj~1i:~]lHi..igR1[~_ <br /> <br />HOPW A Report Form A <br /> <br />p. 2 of 7 <br /> <br />Revised 9/13/05 <br />