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EXHIBITA <br />FORM A <br />HOPWA ACCOMPLISHMENT REPORT <br />Organization: <br />Program or Project: <br />Location: <br />1. Select the one category that best describes service provided with HOPWA Funds: <br />❑ Facility Based Housing (with or w /out Supp Svcs) .................. Submit Form A, B & E <br />❑ Scattered Site: (e.g. TBRA, EFA, STRMU) .............................. Submit Form A, B & C <br />❑ Housing Coordination /Admin .................. ............................... Submit Form A & D <br />❑ Supportive Services Only (e.g. Detox, Life Skills) ................... Submit Form A, B & E <br />2. Check Box Indicating Report Period: <br />❑ 1St Quarter (7/1 — 9/30) ❑ 2nd Quarter <br />❑ 3rd Quarter (ill — 3/31) ❑ 4t' Quarter <br />❑ Year End Report <br />3. Amount of HOPWA Expended In Reporting Period: <br />4. Number of Unduplicated Persons Assisted in Reporting Period: <br />Number of Duplicated Persons Assisted in Reporting Period: <br />5. For Construction Projects, Number of Units Completed: <br />Also Submit Form F <br />(10/1 — 12/31) <br />(411-6130) <br />Please attach applicable Report Forms and a short narrative summary for each project or <br />service funded with HOPWA funds. <br />I certify that the information within this quarterly report is true and correct. <br />Name: <br />Signature: <br />Telephone: Fax : <br />Title: <br />Date: <br />Email: <br />Pag25E -21 Revised 05/05/09 <br />