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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 />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 Support Services Stated: <br /> <br />HOPWA EXPENDITURES (in dollars) <br /> <br />Acquisition: <br />Rehab/Conversion/Repair: <br />Lease: <br />Operating Costs: <br />Other: <br />Other: <br /> <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br />TOTAL: $ <br /> <br />Is the site owned by a public entity? DYes DNa <br />Is this activity "substantial" rehab? DYes DNa <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 />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 />~YEit.itI!fi~l,l/:1~~g~1i~kil\l\E;g~i!l::if~RM <br /> <br />HOPW A Report Fonn 8 <br /> <br />p. 3 of 7 <br /> <br />Revised 9/13/05 <br />