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EXHIBITA <br />FORM B <br />HOPWA DEOMOGRAPHICS REPORT <br />Organization: <br />Program: <br />Persons Receiving Housing Assistance: <br />Number of Persons with HIV/AIDS: <br />Number of Other Family Members: <br />TOTAL: <br />Total Households Receiving Housing Assistance: <br />All Famil Members Under 18 18-30 31-50 Over 50 Total <br />Male: <br />Female: <br />Tota I: <br />Mot <br />thl Income of Households: <br />$0-$250 $251-$500 $501-$1000 $1001-$1500 $1501-$2000 Over $2000 <br />Race I Ehtnicity: <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 />Tota I: <br />Report Race of All I Number of Family Members <br />Family Members Identifvinq as Hispanic! Latino <br />Recent Living Situation: Entering From: Leaving To: <br />Homeless /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 or Friend <br />Rental Housing: <br />Participant-owned Housing: <br />Life Event: <br />Other: <br />Page 2 of 6 Revised 05 /05/09 <br />25E-22 <br />