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EXHIBIT A <br />FORM F <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 Bdrm 1 Bdrms 2 Bdrms 3 Bdrms 4 Bdrms 5+ Bdrms <br />Date of Closing /Lease Execution: <br />Date Construction /Rehab Started: <br />Date Construction /Rehab Completed: <br />Date Operations Staff Hired: <br />Date Residents Began to Occupy: <br />HOPWA EXPENDITURES (in dollars) <br />Acquisition: <br />Rehab /Conversion /Repair: <br />Lease: <br />New Construction: <br />Operating Costs: <br />Technical Assistance: <br />Rental Assistance: <br />Other: <br />Other: <br />Is the site owned by a public entity? <br />Is this activity "substantial" rehab? <br />Available HOPWA Funds: <br />Total HOPWA Funds for Project: <br />Total HOPWA Expended To Date <br />Project Balance Remaining: <br />Leveraging (for year end report only): <br />Non - HOPWA Funds: <br />Value of In -Kind Support: <br />Total of Leveraged Amounts <br />TOTAL: $ <br />❑Yes <br />❑Yes <br />$ <br />❑No <br />❑No <br />Page 6 of 6 Revised 05/05/09 <br />25E -26 <br />