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<br />'. <br /> <br />FORM A <br />HOPWA ACCOMPLISHMENT REPORT <br /> <br />Organization: <br />Program or Project: <br />Location: <br /> <br />1. Select the 2!!! category that best describes service provided with HOPWA Funds: <br /> <br />o Facility Based Housing (with orw/out Supp Svcs) ..................Submit Form A, B & E <br />o Scattered Site: (e.g. TBRA, EFA, STRMU) .............................. Submit Form A, B & C <br />o Housing Coordination/Admin ................................................. Submit Form A & D <br />o Supportive Services Only (e.g. Detox, Life Skills)................... Submit Form A, B & E <br /> <br />2. Check Box Indicating Report Period: <br /> <br />o 1"t Quarter (7/1 - 9/30) <br />o 3rd Quarter (1/1 - 3/31) <br /> <br />o 2nd Quarter <br />o 4th Quarter <br /> <br />(10/1 - 12/31) <br />(411 - 6/30) <br /> <br />o Vear End Report <br />3. Amount of HOPWA Expended In Reporting Period: <br /> <br />$ <br /> <br />4. Number of Unduplicated Persons Assisted in Reporting Period: <br /> <br />Number of Duplicated Persons Assisted in Reporting Period: <br /> <br />5. For Construction Projects. Number of Units Completed: <br /> <br /> <br />. appl cab" Report orm. and a short narrative summary for each project or <br />service ftIncfed with HOPWA funda <br /> <br />I certify that the information within this quarterly report is true and correct. <br /> <br />Name: <br /> <br />Title: <br /> <br />Signature: <br /> <br />Date: <br /> <br />Telephone: <br /> <br />Fax: <br /> <br />Email: <br /> <br />Revised 05/05/05 <br />