2. Funding Source Code/Number Or Contract ID Code/Number

Funding Sources

Please complete a Funding Sources page for each Funding Source for your program, and attach a copy of each grant (mandatory if HUD funded).

1.  Funding Area (Program):

2.  Funding Source Code/Number or Contract ID Code/Number:

3.  Amount ($):

4.  Funding period in years:

5.  Funding Source *(i.e. HUD, CDBG, grant, etc.):

Payment Type: ¨ Reimbursement ¨ Fee For Service

¨ Advance ¨ Program Fee

¨ Other

Contract Code: ¨ New ¨ Renewal

¨Extension

6.  Funding Source Start Date:

7.  Funding Source End Date:

8.  Sponsor: (if different than your agency)

9.  Funding Source Description:

10.  Funding Source Status: ¨ Active ¨ Pending ¨ Closed

11.  Funding Source Contact Person: ___

Title: ¨ Mr. ¨ Mrs. ¨ Miss ¨ Ms. ¨ Dr.

Work Phone: Cell Phone:

Fax Number:

Email:

12.  Target Area(s) or Outcome(s) tied to Funding Source/Contract:

Programs

Please complete these pages for each new program at your agency.

13.  Program Name:

NOTE: The program name should match the program name on your grant applications. Also, housing programs will need to match the program name on the HIC.

14.  Program Type:

NOTE: The program type should match the program type on your grant applications.

¨ Emergency Shelter

¨ Homeless Prevention and Rapid Rehousing

¨ Transitional Housing

¨ Supportive Services Only

¨ Perm. Supportive Housing

¨ Safe Haven

¨ Homeless Outreach

15.  Program Start (MM/DD):

16.  Program End (MM/DD):

17.  Program Description:

18.  Target Population A (please choose one):

A target population is defined as consisting of at least three-fourths (75%) of the residents served by your program. Programs that do not serve a specific target population may leave this question blank.

¨ Single Males 18 Years and Older

¨ Single Females 18 Years and Older

¨ Single Males and Females 18 Years and Older

¨ Couples Only, No Children

¨ Single Males and Households with Children

¨ Single Females and Households with Children

¨ Households with Children

¨ Unaccompanied Males Under 18

¨ Unaccompanied Females Under 18

¨ Unaccompanied Males and Females Under 18

¨ Single Males/Females/Households with Children

19.  Target Population B (please choose one if applicable):

A target population is defined as consisting of at least three-fourths (75%) of the residents served by your program. Programs that do not serve one of the specific target populations may leave this question blank.

¨ Domestic Violence Victims

¨ Veterans

¨ Clients with HIV/AIDS

20.  Does your program receive HUD McKinney-Vento Funds? * Yes * No

(HUD McKinney-Vento funds include: Emergency Shelter Grant (ESG), Shelter plus Care (S+C), Section 8 Moderate Rehabilitation Single-Room Occupancy (SRO), Supportive Housing Program (SHP). HPRP programs are not funded under the McKinney-Vento Act.)

21.  When enrolling clients into the program, would you like to be prompted to ask the standard HUD questions? NOTE: If your program is HUD-funded, you are required to answer these questions.

¨ Yes ¨ No

22.  Bed Inventory by Household Type: (For Year-Round beds only)

Identify the number of beds and units available for each of the following household types.

Voucher and HPRP programs: Please estimate the number of beds and units that will be available for your program. The number of beds should equal the number of individuals served, and the number of units should equal the number of families served. HPRP programs should only include rapid rehousing beds.

Households Without Children

These are beds and units that are reserved for adults only. This includes households composed of unaccompanied adults and multiple adults. The beds counted should be the number of physical beds in the program. This does not include overflow or seasonal beds.

# of Beds ____ # of Units ____

If none, check here *

Households With at Least One Adult and One Child

These are beds and units that are reserved for families with at least one adult and one child. The beds counted should be the number of physical beds in the program. This does not include overflow beds, seasonal beds, or cribs. Units should be the number of families that can be housed in the program. For example, if your program has five apartments, and two families are in each apartment, that would be ten units.

# of Beds ____ # of Units ____

If none, check here *

Households with ONLY Children

These are beds that are reserved for children under the age of 18 only. This includes unaccompanied children, adolescent parents with children, and all other household configurations composed of only children. The beds counted should be the number of physical beds in the program. This does not include overflow beds, seasonal beds, or cribs. Units should be the number of families that can be housed in the program.

# of Beds ____ # of Units ____

If none, check here *

23.  Total Number of Year-Round Beds in the program: ______

24.  Total Number of Year-Round Units in the program: ______

25.  Bed and Unit Availability: (Emergency Shelters ONLY)

# of Seasonal Beds available: Seasonal beds are not available during the whole year, but instead are available on a planned basis, with set start and end dates, during an anticipated period of higher demand.

# of Beds ____ # of Units ____

If none, check here *

Inventory Start Date:______Inventory End Date:______

# of Overflow Beds available: Overflow beds are available on an ad hoc or temporary basis during the year in response to demand that exceeds planned (year round or seasonal) bed capacity.

# of Beds ____ # of Units ____

If none, check here *

26.  Bed Type: (Emergency and Transitional Shelters ONLY)

Please check only ONE

* Facility-based: Beds (including cots or mats) are located in a residential homeless assistance facility dedicated for use by persons who are homeless. For transitional housing programs, the distinguishing characteristic of these beds is that clients must vacate them when they exit the program. Beds may be located in a single facility or multiple facilities, including beds in units that are owned or leased by the program and which a client must leave when they exit the program.

* Voucher: For emergency shelters, beds are located in a hotel or motel and made available by the homeless assistance program through vouchers or other forms of payment. For transitional housing, the voucher bed type should be selected for beds where the program provides a time-limited subsidy in conventional rental housing that clients may continue to occupy after they exit the program (i.e. transition in place or rolling stock transitional housing).

* Other: Beds are located in a church or other facility not dedicated for use by persons who are homeless. For transitional housing programs, this category is not applicable.

27.  Chronically Homeless Beds: (Permanent Supportive Housing Programs ONLY)

How many permanent supportive housing beds does your program have that are readily available and targeted to house chronically homeless persons? _____

Chronically homeless means an individual or family that is homeless and lives or resides in a place not meant for human habitation, a safe haven, or in an emergency shelter; has been homeless and living or residing in a place not meant for human habitation, a safe haven, or in an emergency shelter continuously for at least 1 year or on at least 4 separate occasions in the last 3 years; and has an adult head of household with a diagnosable substance use disorder, serious mental illness, developmental disability, post traumatic stress disorder, cognitive impairments resulting from a brain injury, or chronic physical illness or disability, including the co-occurrence of 2 or more of those conditions.
Persons under the age of 18 are not counted as chronically homeless.
(The number of beds for chronically homeless persons is a subset of the total permanent supportive housing bed inventory for a given program and must be equal to or less than the total bed inventory.)

Locations

Please complete the location page for each location within your program. If all of the clients in your program are served from one location (one building), fill out this form once. If your program serves clients in multiple locations, please fill out this form for each location.

28.  Location Name:______

Address:

City: ___ State: ____ ZIP:

Site Type:

¨ Residential: Special Needs ¨ Non-Residential: Services Only

¨ Residential: Special Needs and Non-Special Needs

Housing Type:

¨ Mass Shelter/Barracks

¨ Dormitory/Hotel/Motel

¨ Shared Housing

¨ Single Room Occupancy Units

¨ Single Apartment (non-SRO) units

¨ Single Homes/Townhouses/Duplexes

¨ Not Applicable: Non-Residential Programs

If a licensed facility:

License ID: Legal Capacity:

Capacity: License Expiration (MM/DD/YYYY):

Location Contact Person:

¨ Director ¨ Administrator ¨ Manager

¨ Case Worker ¨ Staff ¨ Other

Contact Name:

Title: ¨ Mr. ¨ Mrs. ¨ Miss ¨ Ms. ¨ Dr.

Work Phone: Cell Phone:

Fax Number:

Email:

How many beds are at this location? ______

How many family units are at this location? ______

How many individual units are at this location? ______

Services by Program

Please create a services page for each new program.

Program: ______

Service Name / Service Type* / Service Delivered in Units/ Minutes/ Days / How Many Units/ Minutes/ Days per Service? / Cost of Service (to the program) / Service Category** / Service Description / At which location does this service occur?

*Service type: Service, Bed, Session, Case Note, Group Service

**Service category: Food, Material Goods, Transportation, Criminal Justice/Legal Services, Healthcare, Substance Abuse Services, Case/Care Management, Personal Enrichment, Housing/Shelter, Temporary Housing or Other Financial Aid, Consumer Assistance/Protection, Education, HIV/AIDS Related Services, Employment, Day Care, Outreach, Other

Milestones by Program

Please complete this page for each new program.

Program: ______
Milestone Title / Milestone Description / Milestone Verification / Outcome/Target Associated with the Milestone

HMIS Agency Set-Up Page 7 of 8 5/11/2012