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<br /> ' ~ FflR~ ~ <br /> ~OPIN'A DEOI~IOGRA?PHICS REPORT <br /> Organizafion: <br /> Program: <br /> Persons Receiving Housing Assistance: j <br /> Number of Fersans vrith H1V/AIDS: <br /> Number of Other Family Members: <br /> TOTAL: kI <br /> f <br /> Toial Households Receiving Housing Assistance: <br /> Ali Famif Mernbers__ tinder 18 18-30 31-50 Over 50 Total <br /> Male: ~ <br /> Female: <br /> Totai: <br /> Man#hl #ncome of Households: <br /> $0-$250 $251-$500 $501-$1000 $1001$1500 $1501-$2080 • Over$2000 <br /> - <br /> Re ort~Rase of AU Number of F~mity ]41~ritber~ <br /> Race ! ~htnlcity: iFa~it~ iSd'etri_iEeis Idre},i € rr as ~ti azit`s i Lein <br /> American IndianlAEaskan 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. IndianlAlaskan Native & Biack/African Am.: ~ <br /> Other MulEi-Racial: <br /> Balance of individuals reporting more than one race: <br /> Total: <br /> Recent Living Situation; Entering From: Leaving To: <br /> Horrteless /Streets: <br /> Transitional Housing: <br /> Emergency Shelter: _w.~, ~ <br /> Psychiatric Facility: <br /> Substance Abuse Treatment: _ _ <br /> Nospitai / Medical: <br /> Jai! /Prison: 1 <br /> Domestic Violence: j <br /> Giving w/ Relative or friend <br /> Rental Housing: <br /> Participant-owned Housing: <br /> i..ife Bveni: <br /> Other: <br /> ~ <br /> i <br /> Revised 05 /05109 <br /> 25D-25 <br /> <br />