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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 />Mot <br />Total Households Receiving Housing Assistance: <br />All Family Members <br />Under 18 <br />18 -30 <br />31 -50 <br />Over 50 <br />Total <br />Male: <br />Female: <br />Total: <br />thly Income of Households: <br />$0 -$250 $251 -$500 $501 41000 $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 />Total: <br />Report Race of All I Number of Family Members <br />Family Members Identifvina 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 />