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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 bv Pavment TVDe: <br /> <br />SRO 0 Bdrm 1 Bdrm 2 Bdrms 3 Bdrms 4 Bdrms 5+ Bdrms <br /> <br /> <br />Expenditures By Type: <br />Tenant-Based Rent: $ <br /> <br />Rent, Mortgage, Utilities: $ <br /> <br />Total Families Assisted with Housing Assistance: <br /> <br />Program Departure Counts: <br /> <br />Numbe <br /> <br />Volunta <br />Nonpay <br />Support <br />Unknow <br />Crimina <br />Death: <br />Other: <br /> <br />r of Months I <3 3-6 7-12 >12 <br />ry: I <br />ment of rent: <br />ive Service noncompliance: <br />n: <br />I: <br /> <br />Available HOPWA Funds: <br />Allocated HOPWA Funds: <br /> <br />$ <br /> <br />Allocated 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-HOPW A 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 />Sij'l!lii'l1i'j:SJ:jR~' . ': lA'::.'tBljOlll' ~G 'Ii. <br />.",I'.",!!!..",,_. J~..j'. Mc!i\:ilil1.Jl,;!,IL ...~".r"j[l:. ..~,!! <br /> <br />HOPW A Report FOnT> C <br /> <br />p. 4 of 7 <br /> <br />Revised 9/13/05 <br />