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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 />................... <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) ^ 2"d Quarter (10/1 - 12/31 <br />^ 3~d Quarter (1/1 - 3/31) ^ 4t" Quarter (4/1 - 6/30) ) <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 />Please attach applicable Report Forms and a short narrative summary for each <br />service funded with HOPWA funds. <br />I certify that the information within this quarterly report is true and correct. <br />Name: Title: <br />Signature: Date: <br />Telephone: Fax : Email: <br />or <br />Revised 05/05/09 <br />