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EXHIBIT A <br />REPORT FORM A <br />FACILITY BASED HOUSING <br />(Housing Acquisition, Construction or Rehab) <br />FACILITY NAME: <br />FACILITY TYPE: <br />NUMBER OF UNITS BY FACILITY TYPE <br />SRO 0 Bdnn 1 Bdrms 2 Bdrms 3 Bdnns 4 Bdrms 5+ Bdrms <br />Date of ClosinglLease Execution: <br />Date Construction/Rehab Started: <br />Completed: <br />Date Operations Staff Hired: <br />Date Residents Began to Occupy: <br />HDPWA EXPENDITURES (in dotlars) <br />Acquisition: <br />Rehab/Conversion/Repair. <br />Lease: <br />New Construcfron: <br />Operating Costs: <br />Technical Assistance: <br />Renial Assistance: <br />Other: <br />Other. <br />Is the site owned by a public entity? <br />Is this activity "substantial" rehab? <br />Available HDPWA Funds <br />Allocated HDPWA Funds: <br />Allocated HDPWA Program Income: <br />Total HDPWA funds for Project: <br />Total HDPWA Expended to date: <br />Balance HDPWA Funds to date: <br />Source of Non-HDPWA Funds <br /> <br />S <br />S <br />TOTAL: ; <br />^Yes ^No <br />QYes ^No <br /> <br />Expended To Date <br />; <br />Total Non-HDPWA Funds: E <br />Total Available <br />S <br />HDPWA Report FormA 2 of 7 it/1~/09 <br />