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<br />EXHIBIT A <br /> <br />REPORT FORM E <br />SUPPORTIVE SERVICES ONLY <br /> <br />ACTIVITY NAME: <br />ACTIVITY LOCATION <br /> <br />Supportive Services and <br />Housing Assistance <br /> <br />Supportive Services Only <br /> <br />Persons With HIV/AIDS: <br />Other Persons in Family Unit: <br />Total: <br /> <br />SUDDortlve Services <br /> <br />Funds <br />Expended <br /> <br />Unduplicated <br />Clients <br /> <br />Duplicated <br />Clients <br /> <br />1. Outreach $ <br />2. Case MgmVAdvocacy/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. Employment 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 />Available HOPWA Funds: <br /> <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-HOPWA Funds: <br />(Including In-Kind Contributions) <br /> <br />Expended To Date: <br /> <br />Total Available: <br /> <br />$ <br />$ <br />$ <br /> <br />$ <br />$ <br />$ <br /> <br />$ <br /> <br />Total Non-HOPWA Funds: $ <br /> <br />HOPW A Report Fonn E <br /> <br />p. 60f7 <br /> <br />Revised 9/13/05 <br />