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<br />HOPWA SUPP:(~Rn~TAL FORM <br />(To be submitted with Report Forms A, B & C) <br /> <br />DEMOGRAPHICS <br /> <br />Persons Receiving Housing Assistance: <br />Number of Persons with HIV/AIDS: <br />Number of Other Persons in Family Unit: <br />TOTAL: <br /> <br />Total Families Assisted with Housing Assistance: <br /> <br />Ace & Gender Under 18 18-30 31-50 Over 50 Total <br />Male: <br />Female: <br />Total: <br /> <br />Income Grou of Individuals and Famil <br />$0-$250 $251-$500 <br /> <br /> <br />$1001-$1500 <br /> <br />$1501-$2000 <br /> <br />Over $2000 <br /> <br />American Indian/Alaskan Native: <br />Asian: <br />Black/African American: <br />Native Hawaiian/Other Pacific Islander: <br />White: <br />American Indian/Alaskan Native & White: <br />Asian & White: <br />Black/African American & White: <br />Am. Indian/Alaskan Native & Black/African Am.: <br />Other Multi-Racial: <br />Balance of individuals reporting more than one race: <br />Total: <br /> <br />'T"JalnilJribefill.llaclal , :r~~!'l'lHojt~,#!~I'~i1h'~~Illl!o't <br />C"tegQrH'$f!eliQrtlKl ll!l$p~n.esKHI$p~nICl!"rLatli1") <br /> <br />Racial Category: <br /> <br />Recent Living Situation Count: <br /> <br />Homeiess/Streets: <br />Transitional Housing: <br />Emergency Shelter: <br />Psychiatric Facility: <br />Substance Abuse Treatment: <br />Hospital/Medical: <br />Jail/Prison: <br />Domestic Violence: <br />Living w/ Relative/Friend: <br />Rental Housing: <br />Participant-owned Housing: <br />Other: <br /> <br />TOTAL: <br /> <br />SUPPLEMENTAL <br /> <br />Revised <br />9/13/05 <br /> <br />p. 7 of 7 <br />