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General Information
| Exhibit E |
| ADES Domestic Violence Services Monthly Report |
| Agency Name: |
| Location: |
| Month/Year: |
| Instructions for Monthly Report |
| This report is due on or before the 20th day following the end of each month. The Contractor should only complete the sections that correspond to the services (i.e., Shelter, Mobile and/or Community Based Advocacy, and Transitional Housing) that are funded through this contract. All Contractors must complete the "Narrative" section. |
| Report Sections (Tabs below) |
| Shelter Report |
| Mobile and/or Community Based Advocacy (MCBA) Report |
| Transitional Housing (TH) Report |
| Narrative Response |
Shelter Report Shelter Report
Directions: Insert the name and location of your shelter below. If your agency has more than one (1) shelter under this contract, separate the data based on the shelter name/location. ADES has created three (3) separate shelter sections below; feel free to add more if needed.
| SHELTER #1: [Insert Shelter Name and Location Here] |
| Section A – People Served |
| **All clients are counted as new in the month of October** |
| Shelter refers to a shelter facility managed by the Contractor or hotel/motel. Clients who utilize shelter and community/mobile-based services should only be counted in Section A, not in Section C. |
| Instructions for Number of TANF Adults & Children: Provide the number of new adults and children that meet the TANF requirements of having a dependent child and whose income is at or below 250 percent of poverty |
| Instructions for Number of non-TANF Adults & Children: Provide the number of new adults and children that do not meet the TANF requirements of having a dependent child and whose income is at or below 250 percent of poverty. If this information is Unknown, count that in the non-TANF boxes |
| Clients Served in Shelter | |
| Number of New Clients | |
| Number of TANF Adults | |
| Number of TANF Children | |
| Number of non-TANF Adults | |
| Number of non-TANF Children | |
| Total TANF | 0 |
| Total non-TANF | 0 |
| Total Clients Served in Shelter | 0 |
| Section B – Occupancy |
| Instructions for Number of beds available for occupancy during the month: ADES understands that available shelter beds may change due to issues such as family size and health remediations. Please type the number of available beds for the month and the number of days in the month. If the number of available beds changed within the month, please provide an estimation of available beds. |
| Number of beds occupied during the month: Please provide the number of beds actually utilized within the month. |
| Shelter Occupancy | | | |
| Shelter Occupancy | | | |
| # of Beds | # of Days in the month | Total Bed Nights |
| Number of beds available for occupancy during the month | | | 0 |
| Number of beds occupied during the month | | | 0 |
| Section C – Exit |
| Instructions for Number of individuals (adults and children) exited from shelter during the month: Count all individuals who exited from shelter for the month. |
| Individuals exited from shelter |
| Exited |
| Number of individuals (adults and children) exited from shelter during the month |
| Section D – Exit |
| Instructions for Number of individuals (adults and children) moved to safe permanent or transitional housing during the month: For individuals who exited from shelter during this month, count the number of clients who secured safe/stable housing or transitional housing. |
| Individuals exited from shelter to safe permanent housing or transitional housing |
| Exited |
| Number of individuals (adults and children) moved to safe permanent or transitional housing during the month |
Section E – Reasons Shelter Was Not Provided
| Individuals | |
| Shelter Not Provided | |
| No Room | |
| No Show | |
| Other | |
| Total | 0 |
| If other, please explain below: | |
| SHELTER #2: [Insert Shelter Name and Location Here] |
| Section A – People Served |
| **All clients are counted as new in the month of October** |
| Shelter refers to a shelter facility managed by the Contractor or hotel/motel. Clients who utilize shelter and community/mobile-based services should only be counted in Section A, not in Section C. |
| Instructions for Number of TANF Adults & Children: Provide the number of new adults and children that meet the TANF requirements of having a dependent child and whose income is at or below 250 percent of poverty |
| Instructions for Number of non-TANF Adults & Children: Provide the number of new adults and children that do not meet the TANF requirements of having a dependent child and whose income is at or below 250 percent of poverty. If this information is Unknown, count that in the non-TANF boxes |
| Clients Served in Shelter | |
| Number of New Clients | |
| Number of TANF Adults | |
| Number of TANF Children | |
| Number of non-TANF Adults | |
| Number of non-TANF Children | |
| Total TANF | 0 |
| Total non-TANF | 0 |
| Total Clients Served in Shelter | 0 |
| Section B – Occupancy |
| Instructions for Number of beds available for occupancy during the month: ADES understands that available shelter beds may change due to issues such as family size and health remediations. Please type the number of available beds for the month and the number of days in the month. If the number of available beds changed within the month, please provide an estimation of available beds. |
| Number of beds occupied during the month: Please provide the number of beds actually utilized within the month. |
| Shelter Occupancy | | | |
| Shelter Occupancy | | | |
| # of Beds | # of Days in the month | Total Bed Nights |
| Number of beds available for occupancy during the month | | | 0 |
| Number of beds occupied during the month | | | 0 |
| Section C – Exit |
| Instructions for Number of individuals (adults and children) exited from shelter during the month: Count all individuals who exited from shelter for the month. |
| Individuals exited from shelter |
| Exited |
| Number of individuals (adults and children) exited from shelter during the month |
| Section D – Exit |
| Instructions for Number of individuals (adults and children) moved to safe permanent or transitional housing during the month: For individuals who exited from shelter during this month, count the number of clients who secured safe/stable housing or transitional housing. |
| Individuals exited from shelter to safe permanent housing or transitional housing |
| Exited |
| Number of individuals (adults and children) moved to safe permanent or transitional housing during the month |
Section E – Reasons Shelter Was Not Provided
| Individuals | |
| Shelter Not Provided | |
| No Room | |
| No Show | |
| Other | |
| Total | 0 |
| If other, please explain below: | |
| SHELTER #3: [Insert Shelter Name and Location Here] |
| Section A – People Served |
| **All clients are counted as new in the month of October** |
| Shelter refers to a shelter facility managed by the Contractor or hotel/motel. Clients who utilize shelter and community/mobile-based services should only be counted in Section A, not in Section C. |
| Instructions for Number of TANF Adults & Children: Provide the number of new adults and children that meet the TANF requirements of having a dependent child and whose income is at or below 250 percent of poverty |
| Instructions for Number of non-TANF Adults & Children: Provide the number of new adults and children that do not meet the TANF requirements of having a dependent child and whose income is at or below 250 percent of poverty. If this information is Unknown, count that in the non-TANF boxes |
| Clients Served in Shelter | |
| Number of New Clients | |
| Number of TANF Adults | |
| Number of TANF Children | |
| Number of non-TANF Adults | |
| Number of non-TANF Children | |
| Total TANF | 0 |
| Total non-TANF | 0 |
| Total Clients Served in Shelter | 0 |
| Section B – Occupancy |
| Instructions for Number of beds available for occupancy during the month: ADES understands that available shelter beds may change due to issues such as family size and health remediations. Please type the number of available beds for the month and the number of days in the month. If the number of available beds changed within the month, please provide an estimation of available beds. |
| Number of beds occupied during the month: Please provide the number of beds actually utilized within the month. |
| Shelter Occupancy | | | |
| Shelter Occupancy | | | |
| # of Beds | # of Days in the month | Total Bed Nights |
| Number of beds available for occupancy during the month | | | 0 |
| Number of beds occupied during the month | | | 0 |
| Section C – Exit |
| Instructions for Number of individuals (adults and children) exited from shelter during the month: Count all individuals who exited from shelter for the month. |
| Individuals exited from shelter |
| Exited |
| Number of individuals (adults and children) exited from shelter during the month |
| Section D – Exit |
| Instructions for Number of individuals (adults and children) moved to safe permanent or transitional housing during the month: For individuals who exited from shelter during this month, count the number of clients who secured safe/stable housing or transitional housing. |
| Individuals exited from shelter to safe permanent housing or transitional housing |
| Exited |
| Number of individuals (adults and children) moved to safe permanent or transitional housing during the month |
Section E – Reasons Shelter Was Not Provided
| Individuals | |
| Shelter Not Provided | |
| No Room | |
| No Show | |
| Other | |
| Total | 0 |
| If other, please explain below: | |
MCBA Report Mobile and/or Community Based Advocacy (MBCA) Report
Directions: Insert the name and location of your Mobile and/or Community Based Advocacy (MCBA) program below. If your agency has more than one (1) MCBA location under this contract, separate the data based on the MCBA program name/location. ADES has created three (3) separate MCBA section below; feel free to add more if needed.
| MBCA #1: [Insert MCBA Name/Location Here] |
| Section F – People Served |
| All clients are counted as new in the month of October. |
| Instructions for Number of TANF Adults & Children: Provide the number of new adults and children that meet the TANF requirements of having a dependent child and whose income is at or below 250 percent of poverty. |
| Instructions for Number of non-TANF Adults & Children: Provide the number of new adults and children that do not meet the TANF requirements of having a dependent child and whose income is at or below 250 percent of poverty. If this information is Unknown, count that in the non-TANF. |
| Clients Served in Mobile and Community Based Advocacy | |
| Number of New Clients | |
| Number of TANF Adults | |
| Number of non-TANF Adults | |
| Number of TANF Children | |
| Number of non-TANF Children | |
| Total TANF | 0 |
| Total non-TANF | 0 |
| Total Clients Served in Mobile and Community based Advocacy | 0 |
| MBCA #2: [Insert MCBA Name/Location Here] |
| Section F – People Served |
| All clients are counted as new in the month of October. |
| Instructions for Number of TANF Adults & Children: Provide the number of new adults and children that meet the TANF requirements of having a dependent child and whose income is at or below 250 percent of poverty. |
| Instructions for Number of non-TANF Adults & Children: Provide the number of new adults and children that do not meet the TANF requirements of having a dependent child and whose income is at or below 250 percent of poverty. If this information is Unknown, count that in the non-TANF. |
| Clients Served in Mobile and Community Based Advocacy | |
| Number of New Clients | |
| Number of TANF Adults | |
| Number of non-TANF Adults | |
| Number of TANF Children | |
| Number of non-TANF Children | |
| Total TANF | 0 |
| Total non-TANF | 0 |
| Total Clients Served in Mobile and Community based Advocacy | 0 |
| MBCA #3: [Insert MCBA Name/Location Here] |
| Section F – People Served |
| All clients are counted as new in the month of October. |
| Instructions for Number of TANF Adults & Children: Provide the number of new adults and children that meet the TANF requirements of having a dependent child and whose income is at or below 250 percent of poverty. |
| Instructions for Number of non-TANF Adults & Children: Provide the number of new adults and children that do not meet the TANF requirements of having a dependent child and whose income is at or below 250 percent of poverty. If this information is Unknown, count that in the non-TANF. |
| Clients Served in Mobile and Community Based Advocacy | |
| Number of New Clients | |
| Number of TANF Adults | |
| Number of non-TANF Adults | |
| Number of TANF Children | |
| Number of non-TANF Children | |
| Total TANF | 0 |
| Total non-TANF | 0 |
| Total Clients Served in Mobile and Community based Advocacy | 0 |
TH Report Transitional Housing (TH) Report
Directions: Insert the name and location of your Transitional Housing (TH) program below. If your agency has more than one (1) TH location under this contract, separate the data based on the TH program name/location. ADES has created three (3) separate TH sections below; feel free to add more if needed.
| TH #1: [Insert TH Name/Location Here] |
| Section B – People Served |
| **All clients are counted as new in the month of October** |
| Instructions for Number of TANF Adults & Children: Provide the number of new adults and children that meet the TANF requirements of having a dependent child and whose income is at or below 250 percent of poverty. |
| Instructions for Number of non-TANF Adults & Children: Provide the number of new adults and children that do not meet the TANF requirements of having a dependent child and whose income is at or below 250 percent of poverty. If this information is Unknown, count that in the non-TANF. |
| Clients Served in Transitional Housing | |
| Number of New Clients | |
| Number of TANF Adults | |
| Number of non-TANF Adults | |
| Number of TANF Children | |
| Number of non-TANF Children | |
| Total TANF | 0 |
| Total non-TANF | 0 |
| Total Clients Served in Transitional Housing | 0 |
| Section E – Occupancy |
| Instructions for Number of beds available for occupancy during the month: ADES understands that available transitional housing beds may change due to issues such as family size and health remediations. Please type the number of available beds for the month and the number of days in the month. If the number of available beds changed within the month, please provide an estimation of available beds. |
| Instructions for Number of beds occupied during the month: Please provide the number of beds actually utilized within the month. |
| Transitional Housing Occupancy | | | |
| Transitional Housing Occupancy | | | |
| # of Beds | # of Days in the month | Total Bed Nights |
| Number of beds available for occupancy during the month | | | 0 |
| Number of beds occupied during the month | | | 0 |
| Section G – Exit |
| Number of individuals (adults and children) exited from transitional housing during the month: Count all individuals who exited from transitional shelter for the month. |
| Individuals exited from transitional housing |
| Exited |
| Number of individuals (adults and children) exited from transitional housing during the month |
| Section I – Exit |
| [Number of individuals (adults and children) moved to safe permanent housing during the month]: For individuals who exited from transitional housing during this month, count the number of clients who secured safe/stable housing. |
| Individuals exited from transitional housing to safe permanent housing |
| Exited |
| Number of individuals (adults and children) moved to safe permanent housing during the month |
| TH #2: [Insert THE Name/Location Here] |
| Section B – People Served |
| **All clients are counted as new in the month of October** |
| Instructions for Number of TANF Adults & Children: Provide the number of new adults and children that meet the TANF requirements of having a dependent child and whose income is at or below 250 percent of poverty. |
| Instructions for Number of non-TANF Adults & Children: Provide the number of new adults and children that do not meet the TANF requirements of having a dependent child and whose income is at or below 250 percent of poverty. If this information is Unknown, count that in the non-TANF. |
| Clients Served in Transitional Housing | |
| Number of New Clients | |
| Number of TANF Adults | |
| Number of non-TANF Adults | |
| Number of TANF Children | |
| Number of non-TANF Children | |
| Total TANF | 0 |
| Total non-TANF | 0 |
| Total Clients Served in Transitional Housing | 0 |
| Section E – Occupancy |
| Instructions for Number of beds available for occupancy during the month: ADES understands that available transitional housing beds may change due to issues such as family size and health remediations. Please type the number of available beds for the month and the number of days in the month. If the number of available beds changed within the month, please provide an estimation of available beds. |
| Instructions for Number of beds occupied during the month: Please provide the number of beds actually utilized within the month. |
| Transitional Housing Occupancy | | | |
| Transitional Housing Occupancy | | | |
| # of Beds | # of Days in the month | Total Beds |
| Number of beds available for occupancy during the month | | | 0 |
| Number of beds occupied during the month | | | 0 |
| Section G – Exit |
| Number of individuals (adults and children) exited from transitional housing during the month: Count all individuals who exited from transitional shelter for the month. |
| Individuals exited from transitional housing |
| Exited |
| Number of individuals (adults and children) exited from transitional housing during the month |
| Section I – Exit |
| [Number of individuals (adults and children) moved to safe permanent housing during the month]: For individuals who exited from transitional housing during this month, count the number of clients who secured safe/stable housing. |
| Individuals exited from transitional housing to safe permanent housing |
| Exited |
| Number of individuals (adults and children) moved to safe permanent housing during the month |
| TH #3: [Insert TH Name/Location Here] |
| Section B – People Served |
| **All clients are counted as new in the month of October** |
| Instructions for Number of TANF Adults & Children: Provide the number of new adults and children that meet the TANF requirements of having a dependent child and whose income is at or below 250 percent of poverty. |
| Instructions for Number of non-TANF Adults & Children: Provide the number of new adults and children that do not meet the TANF requirements of having a dependent child and whose income is at or below 250 percent of poverty. If this information is Unknown, count that in the non-TANF. |
| Clients Served in Transitional Housing | |
| Number of New Clients | |
| Number of TANF Adults | |
| Number of non-TANF Adults | |
| Number of TANF Children | |
| Number of non-TANF Children | |
| Total TANF | 0 |
| Total non-TANF | 0 |
| Total Clients Served in Transitional Housing | 0 |
| Section E – Occupancy |
| Instructions for Number of beds available for occupancy during the month: ADES understands that available transitional housing beds may change due to issues such as family size and health remediations. Please type the number of available beds for the month and the number of days in the month. If the number of available beds changed within the month, please provide an estimation of available beds. |
| Instructions for Number of beds occupied during the month: Please provide the number of beds actually utilized within the month. |
| Transitional Housing Occupancy | | | |
| Transitional Housing Occupancy | | | |
| # of Beds | # of Days in the month | Total Beds |
| Number of beds available for occupancy during the month | | | 0 |
| Number of beds occupied during the month | | | 0 |
| Section G – Exit |
| Number of individuals (adults and children) exited from transitional housing during the month: Count all individuals who exited from transitional shelter for the month. |
| Individuals exited from transitional housing |
| Exited |
| Number of individuals (adults and children) exited from transitional housing during the month |
| Section I – Exit |
| [Number of individuals (adults and children) moved to safe permanent housing during the month]: For individuals who exited from transitional housing during this month, count the number of clients who secured safe/stable housing. |
| Individuals exited from transitional housing to safe permanent housing |
| Exited |
| Number of individuals (adults and children) moved to safe permanent housing during the month |
Narrative Response Narrative Response
| Section K – Narrative Response – MANDATORY – DO NOT SKIP |
| For the survivors who did not move to safe/stable or transitional housing, please describe the challenges or barriers they faced to accessing stable housing. |
| Remember, do NOT include any personally identifying information. |