STATE OF CALIFORNIA DEPARTMENT OF HOUSING AND COMMUNITY DEVELOPMENT

ANNUAL PERFORMANCE REPORT DIVISION OF FINANCIAL ASSISTANCE

HCD DFA FESG 03 (Rev. 04/09) FEDERAL EMERGENCY SHELTER GRANT

Federal Emergency Shelter Grant

Annual Performance Report

(Period Covered: July 1, 2008 through June 30, 2009)

Grantee Name: ______

Grant Number: _____-FESG-____Program/Project Name: ______Address: ______(c Confidential)

City: ______County: ______

Contact Person: ______

Phone No.: ______

Fax No.: ______Email Address: ______

1. ESG HOUSING AND SERVICES:

Indicate program(s) and service(s) with an “X”. (Check all that apply).
Emergency Shelter Facilities / Transitional Shelter
Vouchers For Shelters / Outreach
Drop-In Center / Soup Kitchen/Meal Distribution
Food Pantry / Health Care
Mental Health / HIV/AIDS Services
Alcohol/Drug Program / Employment
Child Care / Homeless Prevention
Other
Indicate type of organization carrying out the activity with an “X”.
Public Agency
Faith Based non-profit
Other non-profit

2. OBJECTIVE AND OUTCOME: (Do not check any)

Objective
1.Create suitable living environment / X
2.Provide decent affordable housing
3. Create economic opportunities
Outcome
1. Availability/accessibility / X
2. Affordability
3. Sustainability

3. ESG BENEFICIARIES:

Residential services / Non-residential services Total
Annual Number Adults Served / Annual Number of Adults and Children Served
Annual Number Children Served
Total

4. RACIAL/ETHNIC CHARACTERISTICS: (Residential services and non–residential services).

Annual number served #Total #Hispanic
White
Black/African American
Asian
American Indian/Alaskan Native
Native Hawaiian/Other Pacific Islander
American Indian/Alaskan Native & White
Asian & White
Black/African American & White
American Indian/Alaskan Native & Black African American
Other Multi-Racial
TOTALS

5.  ESG BENEFICIARIES: (Residential services only).

Annual number of individual households (singles): Male Female Total
Unaccompanied 18 and Over
Unaccompanied Under 18
Annual number of family households with
children headed by: Male Female Total
Single 18 and Over
Single Under 18
Two Parents
18 and Over
Two Parents Under 18
Annual number of family households with no children
TOTAL

6. ESG BENEFICIARIES:( Residential services only)

List the number of persons for each subpopulation you served. If you served subpopulations that fit more than one category, you may place overlapping numbers (duplicate persons) on the appropriate lines.

Annual number served who are:
Chronically Homeless(Emergency Shelter Only)
Severely Mentally Ill
Chronic Substance Abuse
Other Disability
Veterans
Persons with HIV/AIDS
Victims of Domestic Violence
Elderly

7. ESG HOUSING: ( Residential services only)

Annual number served
in emergency or transitional shelters
Shelter type / No. of persons housed
Barracks
Group/Large House
Scattered Site Apartment
Single Family Detached House
Single Room Occupancy
Mobile Home/Trailer
Hotel/Motel
Other:______
TOTAL

8. FUNDING SOURCES:

Funding sources Dollars
ESG
Other Federal
Local Government
Private
Fees
Other
TOTAL

NOTE: This Annual Performance Report (APR) is due by July 20th of each grant year.

You may email the APR and submit a hard copy to:

Dan Apodaca, Program Manager,

Housing and Community Development Department

Division of Financial Assistance

1800 3rd Street Room, 390-4

Sacramento, CA 95814

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