Organization and Project Identifiers

Organization Name
Operating Start Date / Operating End Date
Organization Address / Notes about any changes to Organization Name,
Project Name or Project Type
Project Name
Project Type / Check ONE
1. Check only one Project Type. / Coordinated Assessment
Day Shelter
Emergency Shelter
Homelessness Prevention
Other
PH - Permanent Supportive Housing (disability required for entry)
PH - Rapid Rehousing
PH - Housing with Services (no disability required for entry)
PH - Housing Only
Retired (no longer entering data)
Safe Haven
Services Only
Street Outreach
Transitional Housing
Affiliated with a Residential Project: / □ Yes □ No If yes, list project
Housing Type / □ Site-Based-Single Site □ Site-Based-clustered/multiple sites □ Tenant-based-scattered site
Principal Site / □ Yes □ No / Target Population / □ DV: Domestic Violence victims □ HIV: Persons with HIV/AIDS □ NA: Not Applicable
Victim Services Provider / □ Yes □ No
Method for Tracking Emergency Shelter Utilization / □ Entry/Exit □ Night by Night
Continuum Project / □ Yes □ No
Provider Grant Type / □ HOPWA □ RHY □ PATH □ SSVF
Service Transaction Workflow / □ Yes □ No
CoC Code / □ NE-500 Balance of State □ NE-502 Lincoln / CoC Code Start Date / CoC Code End Date
Geocode
ZipCode
Geography Type / □ Urban □ Suburban □ Rural

Please complete this form for each of your projects annually and return to Angel Shafer at and Abby White at or via fax at 402-472-8412

Federal Partner Program / Funding Source / Grant Identifier / Start Date / End Date
1.  Check all funding sources for a Project Type.
2.  A Grant Identifier number is needed for each funding source.
3.  Start Date is the date for the start of the grant cycle.
4. End Date is for the date of the end of the grant cycle. / HUD:CoC - Homeless Prevention (High Performing Comm. Only)
HUD:CoC - Permanent Supportive Housing
HUD:CoC - Rapid Re-housing
HUD:CoC - Supportive Services Only
HUD:CoC - Transitional Housing
HUD:CoC - Save Haven
HUD:CoC - Single Room Occupancy (SRO)
HUD:CoC-Youth Homeless Demonstration Program (YHDP)
HUD:ESG - Emergency Shelter (operating and/or essential services)
HUD:ESG - Homeless Prevention
HUD:ESG - Rapid Re-housing
HUD:ESG - Street Outreach
HUD: Rural Housing Stability Assistance Program
HUD:HUD/VASH
HUD: Pay for Success
HUD: Public and Indian Housing (PIH) Programs
HHS: PATH- Street outreach Supportive Services Only
HHS: RHY-Basic Center Program (prevention and shelter)
HHS: RHY-Maternity Group Home for Pregnant and Parenting Youth
HHS: RHY-Transitional Living Program
HHS: RHY-Street Outreach Project
HHS: RHY-Demonstration Project
VA: CRS Contract Residential Housing
VA: Domiciliary Care
VA: Grant Per Diem-Bridge Housing
VA: Grant Per Diem-Low Demand
VA: Grant Per Diem-Hospital to Housing
VA: Grant Per Diem-Clinical Treatment
VA: Grant Per Diem-Service Intensive Transitional Housing
VA: Grant Per Diem-Transition in Place
VA: Community Contract Safe Haven Program
VA: Compensated Work Therapy Transitional Residence
VA: Supportive Services for Veteran Families
N/A

Please complete this form for each of your projects annually and return to Angel Shafer at and Abby White at or via fax at 402-472-8412