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EXHIBIT A <br />- REPORT FORM C <br />SCATTERED SITE HOUSING ACTIVITY ' <br />(Tenant Based Rental Assistance, Emergency Housing/Ublity Assistance) <br />Activity Name: <br />Activity Location: ~ Date Payments Began: <br />Number of Un'rts Assisted by Payment Tyne <br />SRO 0 Bdrm i Bdrm 2 Bdrms 3 Bdrms 4 Bdrms . 5+ Bdrms <br />Tenant-Based Rent <br />Rent, Mortgage, Ut~7iGes <br />Expenditures By Type: Tenant-Based Rent: Rent, Mortgage, Utilities: ~ <br />Total Families Assisted with Housing Assistance: <br />Program Departure Counts <br />Number of Months <3 3-6 7-12 >12 <br />Voluntary: <br />Nonpayment of rent: <br />Supportive Service noncompliance: <br />t.hrknoMm: <br />Crirnirral: <br />Death: <br />Other <br />HOPWA EXPENDITURES th doNars) . <br />Allocated HOPWA Funds: <br />. Allocated HOPWA Program Income: <br />Total HOPWA funds for Project: <br />Total HOPWA Expended io date: <br />Balance HOPWA Funds to date: <br />Source of Non-HOPWA Funds <br />Total Non-HOPWA Funds: <br />HOPWA~~~~ C <br />S <br />+; <br />=3 <br />-; <br />_~ <br />Total Available Expended To Date <br />S ~ S <br />S <br />S <br />S <br />S <br />S <br />2~0~ 7 ~ ~ 11/12/Q4 <br />