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<br />. " <br /> <br />FORM B <br />HOPWA DEOMOGRAPHICS REPORT <br /> <br />Organization: <br />Program: <br /> <br />Persons Receiving Housing Assistance: <br />Number of Persons with HIV/AID5: <br />Number of Other Family Members: <br />TOTAL: <br /> <br />Total Households Receiving Housing Assistance: <br /> <br />All Famllv Members Under 18 18-30 31-50 Over 50 Total <br />Male: <br />Female: <br />Total: <br /> <br />Man hi I <br /> <br />t IV ncome 0 ouse 0 s: <br />$0-$250 $251-$500 $501-$1000 $1001-$1500 $1501-$2000 Over $2000 <br /> <br />fH <br /> <br />h Id <br /> <br />Race / Ehtnlclty: <br /> <br />Report-'olAII <br />Faml'" Mambers <br /> <br />Number 01 Family Mambe.. <br />Id.nllfYlng .. HI.oante I LaUno <br /> <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 /> <br />Recent Living Situation: <br /> <br />Entering From: <br /> <br />Leaving To: <br /> <br />Homeless / Streets: <br />Transitional Housing: <br />Emergency Shelter. <br />Psychiatric Facility: <br />Substance Abuse Treatment: <br />Hospital I Medical: <br />Jail/ Prison: <br />Domestic Violence: <br />Living wi Relative or Friend <br />Rental Housing: <br />Participant-owned Housing: <br />Life Event: <br />Other: <br /> <br />Revised 05 105109 <br />