Exhibit_E_-__ADES_Domestic_Violence_Services_Monthly_Report.xlsx

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Attached to
Master Agreement AZ|CTR066195
Contract number
CTR066195
Issued by
Arizona

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This document is an Excel-based monthly reporting template for the Arizona Department of Economic Security (ADES) Domestic Violence Services contract. The template is designed for contractors providing domestic violence support services, specifically outlining reporting requirements for shelter, mobile/community-based advocacy, and transitional housing programs. The form requires detailed monthly reporting across multiple service categories, with sections for tracking client demographics, occupancy rates, client exits, and housing transitions.

The reporting template focuses on capturing comprehensive data about domestic violence service delivery, including the number of new clients served (categorized by TANF and non-TANF adults and children), bed occupancy, client exits, and housing outcomes. Contractors must complete the report by the 20th day following each month's end, providing granular details about service provision across up to three locations for each service type (shelter, mobile advocacy, and transitional housing). The form requires a mandatory narrative response explaining challenges survivors face in accessing stable housing, with strict instructions to protect client privacy by avoiding personally identifying information.

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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 TANF0
Total non-TANF0
Total Clients Served in Shelter0
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 monthTotal Bed Nights
Number of beds available for occupancy during the month0
Number of beds occupied during the month0
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
Total0
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 TANF0
Total non-TANF0
Total Clients Served in Shelter0
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 monthTotal Bed Nights
Number of beds available for occupancy during the month0
Number of beds occupied during the month0
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
Total0
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 TANF0
Total non-TANF0
Total Clients Served in Shelter0
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 monthTotal Bed Nights
Number of beds available for occupancy during the month0
Number of beds occupied during the month0
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
Total0
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 TANF0
Total non-TANF0
Total Clients Served in Mobile and Community based Advocacy0
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 TANF0
Total non-TANF0
Total Clients Served in Mobile and Community based Advocacy0
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 TANF0
Total non-TANF0
Total Clients Served in Mobile and Community based Advocacy0

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 TANF0
Total non-TANF0
Total Clients Served in Transitional Housing0
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 monthTotal Bed Nights
Number of beds available for occupancy during the month0
Number of beds occupied during the month0
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 TANF0
Total non-TANF0
Total Clients Served in Transitional Housing0
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 monthTotal Beds
Number of beds available for occupancy during the month0
Number of beds occupied during the month0
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 TANF0
Total non-TANF0
Total Clients Served in Transitional Housing0
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 monthTotal Beds
Number of beds available for occupancy during the month0
Number of beds occupied during the month0
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.

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