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EXHIBIT A <br />REPORT FORM A <br />FACILITY BASED HOUSING <br />(Housing Acquisition, Construction or Rehab) <br />FACILITY NAME: <br />FACILfTY TYPE: <br />NUMBER OF UNRS BY FACILIT/ TYPE <br />SRO 0 Bdrm 1 BdlTns 2 Bdrms 3 Bdrnis 4 Bdrms 5+ 6drms <br />Date of Closing/Lease Execution: <br />Date ConstructionlRehab Started: <br />Completed: <br />Date Operations Staff Hired: <br />Date Residents Began to Occupy: <br />HOPWA EXPENDITURES (in dollars) <br />Acquisftion: <br />Reha WConversion/Repair. <br />Lease: <br />New Construction: <br />Operating Costs: <br />Technical Assistance: <br />Rental Assistance: <br />other: <br />Other: <br />TOTAL: <br />is the site owned by a public entity? <br />Is this activity "substantial" rehab? <br />Available HOPWA Funds <br />Allocated HOPWA Funds: <br />Allocated HOPWA Program Income: <br />Total HOFWA funds for ProjecL• <br />Total HOPWA Expended to date: <br />Balance HOPWA Funds to date: <br />Source of Non-HOPWA Funds <br />S <br />S <br />i <br />^Yes ^No <br />^Yes ^No <br />+; <br />=E <br />-E <br />=a <br />Expended To Date Total Available <br />S S <br />Total Non-HOPWA Funds: E S <br />M3~ST~~t~' a : ~ORe , ia~'M <br />HOPWA Report Form A 2 Of 7 11/12/04 <br />