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EXHIBIT A <br />REPORT FORM B <br />FACILITY-BASED NON-HOUSING <br />(Property Acquisition, Construction or Rehab) <br />Activity Name: <br />Facility Type: _ <br />Date of Ciosing/Lease Execution: <br />Date Construction/Rehab Started: <br />Date ConstructionlRehab Completed: <br />Date Operations Staff Hired: <br />Date Support Services Started: <br />HOPWA Site Expenditures (in douars) <br />Acquisition: <br />Reha blConversion/Repair: <br />Lease: <br />Operating Costs: <br />Other: <br />Other: <br />Is the ske 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 HOPWA funds for Project: <br />Total HOPWA Expended to date: <br />Balance HOPWA Funds to date: <br />Source Of Non-HOPWA Funds <br />Total Non-HOPWA Funds: <br />^Yes <br />^Yes <br />S <br />S <br />S <br />^No <br />^No <br />S <br />+j <br />=3 <br />-S <br />=E <br />Total Available <br />S <br />t AL1.RY~°a~ 3U A ~`t' ~~R.9~~©'i ~lr'-'i'~.4Y4.1 <br />3 of 7 <br />TOTAL: <br />Expended To Date <br />S <br />HOPWA RepoA form a 11/i?/04 <br />