HUD-50900 Elements for the Annual Moving to Work Plan and Annual M

OMB Control Number: 2577-0216 Expiration Date: 5/31/2016

Form 50900: Elements for the Annual MTW Plan and Annual MTW Report

Attachment B

to
AMENDED AND RESTATED MOVING TO WORK AGREEMENT
BETWEEN
U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT
AND
MOVING TO WORK (MTW) HOUSING AGENCIES

The information on this form is being collected so that HUD is able to evaluate the impacts of MTW activities; respond to congressional and other inquiries regarding outcome measures; and identify promising practices learned through the Moving to Work (MTW) demonstration. The information collected through this form is not confidential. MTW public housing authorities (PHAs) will report outcome information on the effects of MTW policy changes on residents, the agency's operations, and the local community. The estimated burden per year, per agency, is 81 hours. Responses to this collection of information are required to obtain a benefit or to retain a benefit. HUD may not conduct or sponsor, and MTW agencies are not required to respond to, a collection of information unless that collection displays a valid OMB control number. All MTW PHAs will provide the following required elements in the order and format given in the 50900 in their Annual MTW Plans and Annual MTW Reports, consistent with the requirements in Section VII of the Standard MTW Agreement.

General Instructions for MTW Plan and Reports

Section Numbering: Some sections of the Form 50900 have been combined since the prior version of the form, resulting in the sections being renumbered. The sections are now as follows: (I) Introduction, (II) General Housing Authority Operating Information, (III) Proposed MTW Activities, (IV) Approved MTW Activities, (V) Sources and Uses of Funds, and (VI) Administrative.

Format Requirements: MTW PHAs are required to use the HUD generated spreadsheets for Sections (II) and (V) of the Form 50900. There is no prescribed format for presenting the required information in Sections (I), (III), (IV) or Section (VI) of the Form 50900, but all required information must be clearly provided. MTW PHAs can use a customized format or the same format the agency has been using for past MTW Plan/Report submissions for these sections. MTW PHAs must, however, incorporate the "Standard HUD Metrics" in the order and format provided in this Form for Section (III) Proposed MTW Activities and as applicable in Section (IV) Approved Activities. HUD prefers that agencies also report agency-developed metric information in a similar format.

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OMB Control Number: 2577-0216 Expiration Date: 5/31/2016

Submission Requirements (dissemination): MTW PHAs shall follow submission requirements as set forth in the Standard MTW Agreement and shall provide the initial submission of the Annual MTW Plan and the Annual MTW Report to HUD Headquarters and the agency's local HUD Field Office via an electronic format. Preferably, this transmittal will occur via email, but CD/DVD or USB flash drive submissions are acceptable. Submissions using File Transfer Protocol (FTP) and other forms of data download that require HUD staff to log-on to a web portal will require prior approval by the MTW Program Director.

Submission Requirements (file type): The electronic submission shall include a searchable PDF version (not a scanned PDF) of the Plan/Report or a Microsoft Word document version of the Plan/Report. The body of the MTW Plan/Report shall be submitted as one file type and preferably in one file. The body shall include the HUD-generated spreadsheets for Sections (II) and (V) and the HUD Standardized Metrics incorporated into Sections (III) and (IV). Sections (II) and (V) should also be provided as a separate Microsoft Excel file. Supplemental materials (e.g. Capital Fund forms, signed Board Resolution, other appendix information) may be submitted in a different file type.

Submission Requirements (hard copy) : Once HUD has provided either an approval letter for the PHA's Annual MTW Plan or an acceptance letter for the PHA's Annual MTW Report, the PHA will submit a final hard copy and electronic copy of the Plan/Report to HUD Headquarters and the PHA's local HUD Field Office, as stated in the Standard MTW Agreement in Section VII.A.1.c. A hard copy of the Plan/Report is not required until an approval/acceptance letter is issued by HUD.

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OMB Control Number: 2577-0216 Expiration Date: 5/31/2016

Section-by-Section Instructions for MTW Plans and Reports

Section I: Introduction

Generally: PHAs will include short-term and long-term MTW goals and objectives in this section. This new section combines Sections I (Introduction) and IV (Long-Term MTW Plan) from the previous version of Form 50900: OMB Control Number 2577-0216, Expiration Date 12/31/2011.

Section II: General Housing Authority Operating Information

Generally: A pre-formatted Microsoft Excel table has been provided for PHAs to report the required housing stock, leasing and waitlist information in this section. PHAs will copy and paste the HUD provided Microsoft Excel tables into the body of Section (II) in their Plan/Report. With the initial submittal of each Plan/Report to HUD, the PHA will also include the completed, separate Microsoft Excel file. A PHA may include updates to its historical housing stock or leasing tables as an appendix to the Plan/Report. The PHA may reference such an appendix in Section (II) of the Plan/Report to direct readers to this information.

Section II.A Housing Stock Information

General Description of All Planned Capital Fund Expenditures: PHAs are required to provide a general description of planned capital expenditures by development.

Section II.B: Leasing Information

Definition of Households Served: "Households Served" under MTW includes all households that receive housing assistance, directly or indirectly, using any amount of MTW funds. Housing assistance through local, non-traditional MTW programs is included, as long as the activity conforms to the requirements stipulated in the Standard MTW Agreement and PIH Notice 2011-45.

Categories of Households Served: “Households Served” data will be reported in four categories: Federal MTW Public Housing Units Leased; Federal MTW Voucher (HCV) Units Utilized; Number of Units Occupied/Leased through Local Non-Traditional MTW Funded Tenant-Based Assistance Programs, and Number of Units Occupied/Leased through Local Non-Traditional MTW Funded Project-Based Assistance Programs. Additionally, HUD will track “Households Served through Local, MTW Funded Non-Traditional Services Only.” These households, however, will not be included in the “Total Households Served/Units Leased” calculation used to determine if the PHA is continuing to assist substantially the same total number of eligible low-income families as would have had the agency not combined its funds (as set forth in PIH Notice 2013-2). The definitions for these categories are provided below.

• Federal MTW Public Housing Units Leased refers to the count of households that reside in any unit of

housing authorized and funded under an Annual Contributions Contract (ACC) between the PHA and HUD pursuant to the U.S. Housing Act of 1937.

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OMB Control Number: 2577-0216 Expiration Date: 5/31/2016

• Federal MTW Voucher (HCV) Units Utilized refers to households that receive rental assistance

through Housing Assistance Payment (HAP) Contracts (pursuant to an ACC between HUD and the PHA) paid for with MTW funds at a location selected by the household and not tied to a specific location OR households that receive rental assistance through HAP Contracts (pursuant to an ACC between HUD and the PHA) paid for with MTW funds at a specific location that is not public housing.

• Units Occupied/Leased through Local, Non-Traditional MTW Activities refers to households or

families that receive assistance through an MTW tenant-based or project-based housing program, or other type of assistance (i.e. Homeownership) outside of Sections 8 and 9 of the 1937 Housing Act. This includes all households at or below 80% are median income (AMI) that receive housing through MTW funds but not through traditional Public Housing or Housing Choice Vouchers. This could include low-income housing tax-credit (LIHTC) households if MTW funds were used for development costs or as a subsidy, as well as households that benefit from MTW funds that are not direct rental subsidies but are used in the development of below-market rate units restricted to eligible households.

• Households Served through Local, MTW Funded Non-Traditional Services Only are households at or

below 80% AMI provided services through the MTW-funded block grant and not assisted through any type of housing assistance for the fiscal year and over the course of the agency's participation in the demonstration. Households that are only receiving services and are also on one of the PHA's housing waiting lists should be included in this category.

Section II.C: Waitlist Information

Waitlist Information Submittal : A pre-formatted Microsoft Excel template will collect three aspects of the PHA's aggregate waitlists, including: the waitlist type, the number of households on the waitlist and whether the waitlist is open or closed. Waitlist information will include those managed by the PHA and those managed by a third party. PHAs may include additional narrative to provide explanations for changes to the waitlist(s) in the body of the Plan/Report.

Section III: Proposed MTW Activities and Section IV: Approved MTW Activities

Use of Standard HUD Metrics: PHAs are required to track all applicable "Standard HUD Metrics" under each statutory objective cited for the proposed MTW activity. Standard metrics must be given in the table format provided in the "HUD Standard Metrics" Section of the Form 50900 in order to allow analysis and aggregation across agencies for similar activities.

Additional Metrics: PHAs may report on agency-developed and previously established metrics in addition to the required HUD Standard Metrics.

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OMB Control Number: 2577-0216 Expiration Date: 5/31/2016

Section IV: Approved MTW Activities

Generally: This section includes four subsections: Implemented, Not Yet Implemented, On Hold, and Closed Out. Once an activity is approved it must be placed in Section (IV) under one of these four subcategories. Definitions of these categories are given below.

• Implemented includes MTW activities in which the PHA is actively engaged.

• Not Yet Implemented includes activities in which the PHA is not actively engaged but is preparing to

implement in the future.

• On Hold includes activities that were previously implemented, that the PHA stopped implementing,

but that the PHA plans to reactivate in the future.

• Closed Out includes activities that were MTW activities, but are now obsolete because they no longer

require MTW authorization due to changes in regulation, activities completed because the PHA accomplished its stated objectives and no longer requires the use of MTW flexibility, activities that the PHA has decided to end before attaining the activity's objectives, or activities the PHA has never implemented and does not plan to implement at any point in the future. In the year the activity is ended the PHA is required to provide information about the outcomes of the activity.

Use of Standard HUD Metrics: Standard metrics must be shown in the table format provided in the "HUD Standard Metrics" Section of the Form 50900 in order to allow analysis and aggregation across agencies for similar activities.

• Ongoing, Implemented Activities: PHAs are required to use all of the applicable "Standard HUD Metrics" under each statutory objective cited for the approved MTW activities in the "Implemented" category.

• Not Yet Implemented and On Hold Activities: Since the PHA would not currently be engaged in these categories of approved activities, it is not necessary to include Standard HUD Metrics until implementation.

• Closed Out Activities: PHAs are required to use all of the applicable "Standard HUD Metrics" under each statutory objective cited in the final reporting of activities in the "Closed Out" category.

Significant Changes to Activities: HUD requires PHAs to re-propose activities that require "significant changes." A "significant change" occurs when the nature of the activity has changed such that an additional MTW authorization is needed OR when a PHA fundamentally changes the nature and scope of an activity to the extent that there is the potential for a different impact on residents (e.g. changing the calculation of rent). In these cases, the activity must undergo a new public process. HUD reserves the right to determine on a case-by-case basis if the change made to an activity crosses this threshold and therefore requires the activity to be re-proposed.

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Section V: MTW Sources and Uses of Funds

Generally: A pre-formatted Microsoft Excel table has been provided for PHAs to report the required information in this section. PHAs will copy and paste the HUD-provided Microsoft Excel tables into the body of Section (V) in their Plan/Report. With the initial submittal of the Plan/Report to HUD, the PHA will also include the completed, separate Microsoft Excel file. A PHA may include additional information regarding sources and uses of funding as an appendix to the Plan/Report. The PHA may reference such an appendix in Section (V) of the Plan/Report to direct readers to this information.

Section VI: Administrative

Board Resolution Submittal: There is no predetermined format for submission of the required resolution signed by the Board of Commissioners or other authorized PHA official adopting the Annual MTW Plan Certification of Compliance.

Certification of Meeting the MTW Statutory Requirements Submittal: There is no predetermined format for submission with the Annual MTW Report of the required certification that the PHA has met the three MTW statutory requirements.

Additional Appendix Items

Appendix Information Submittal: The PHA may submit additional appendix items as it deems appropriate. Particular MTW PHAs may be required to submit additional appendix items depending on the content of the particular Standard MTW Agreement and Annual MTW Plan (examples include RHF Plan, Local Asset Management Plan, etc.)

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OMB Control Number: 2577-0216 Expiration Date: 5/31/2016

Form 50900: Elements for the Annual MTW Plan and Annual MTW Report Attachment B
(I) Introduction
Annual MTW Plan	Annual MTW Report
A. Table of Contents, which includes all the required elements of the Annual MTW Plan; and	A. Table of Contents, which includes all the required elements of the Annual MTW Report; and
B. Overview of the PHA's short-term and long- term MTW goals and objectives. Short-term goals and objectives include those that the PHA plans to accomplish within the fiscal year. Long- term goals and objectives include those that the PHA plans to accomplish beyond the current fiscal year. PHAs have the ability to define the level of specificity in the short-term and long-term goals and objectives. If PHAs are including non-MTW components in either the short-term or long-term goals and objectives, the PHA should clearly delineate which are MTW and which are non-MTW goals and objectives. PHAs have the flexibility to include references to proposed and ongoing activities in this section if it assists in providing an explanation about short-term and long-term goals and objectives. However, this is not required.	B. Overview of the PHA's short-term and long­term MTW goals and objectives. The PHA should include information about whether short-term goals and objectives were accomplished and report progress towards long-term goals and objectives.

Attachment B

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OMB Control Number: 2577-0216 Expiration Date: 5/31/2016

Form 50900: Elements for the Annual MTW Plan and Annual MTW Report

Attachment B

(II) General Housing Authority Operating Information

Annual MTW Plan

II.1.Plan.HousingStock

A. MTW Plan: Housing Stock Information

Planned New Public Housing Units to be Added During the Fiscal Year

# of UFAS Units

Total Public Housing Units to be Added

0

* Select Population Type from: Elderly, Disabled, General, Elderly/Disabled, Other

If Other, please describe: Description of "other" population type served

Type Noted *

X

Type Noted *

X

X

Type Noted *

X

Type Noted *

AMP Name and Number

Bedroom Size Total

Units

Fully Accessible Adaptable

Type *

0 1 2 3 4 5 6+

Population

X	X
X	X
X	X
X	X

PIC Dev. # /AMP PIC Dev. Name	X	X	X	X	X	X	X
PIC Dev. # /AMP PIC Dev. Name	X	X	X	X	X	X	X
PIC Dev. # /AMP PIC Dev. Name	X	X	X	X	X	X	X
PIC Dev. # /AMP PIC Dev. Name	X	X	X	X	X	X	X

Explanation for Removal

Explanation for Removal

Explanation for Removal

PIC Dev. # / AMP and PIC Dev. Name

Number of Units to be

Explanation for Removal

Removed

PIC Dev. # /AMP
PIC Dev. Name

PIC Dev. # /AMP
PIC Dev. Name

PIC Dev. # /AMP
PIC Dev. Name

Total Number of Units to be Removed

X

X

X

0

Planned Public Housing Units to be Removed During the Fiscal Year

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Other Changes to the Housing Stock Anticipated During the Fiscal Year

General Description of All Planned Capital Fund Expenditures During the Plan Year

Narrative general description of all planned capital fund expenditures during the Plan year (by development)

New Housing Choice Vouchers to be Project-Based During the Fiscal Year
Property Name		Anticipated Number of New Vouchers to be Project-Based *		Description of Project
Property Name		X		Description of project 1
Property Name		X		Description of project 2
Property Name		X		Description of project 3
Property Name		X		Description of project 4
Anticipated Total New Vouchers to be Project-Based				Anticipated Total Number of Project-Based Vouchers Committed at the End of the Fiscal Year Anticipated Total Number of Project-Based Vouchers Leased Up or Issued to a Potential Tenant at the End of the Fiscal Year
		0			X
					X

*New refers to tenant-based vouchers that are being project-based for the first time. The count should only include agreements in which a HAP agreement will be in place by the end of the year.

Description of other changes to the housing stock anticipated during the fiscal year

Description of other changes to the housing stock anticipated during the fiscal year

Description of other changes to the housing stock anticipated during the fiscal year

Examples of the types of other changes can include but are not limited to units that are held off-line due to the relocation of residents, units that are off-line due to substantial rehabilitation and potential plans for acquiring units.

OMB Control Number: 2577-0216 Expiration Date: 5/31/2016

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OMB Control Number: 2577-0216 Expiration Date: 5/31/2016

II.2.Plan.Leasing
B. MTW Plan: Leasing Information
Planned Number of Households Served at the End of the Fiscal Year
	Planned Planned Number of Number of Unit MTW Households to be Served Through: Households to be Months Served* Occupied/ Leased***
	Federal MTW Public Housing Units to be Leased			X	X
	Federal MTW Voucher (HCV) Units to be Utilized			X	X
	Number of Units to be Occupied/Leased through Local, Non-Traditional, MTW Funded, Property-Based Assistance Programs **			X	X
	Number of Units to be Occupied/Leased through Local, Non-Traditional, MTW Funded, Tenant-Based Assistance Programs **			X	X
	Total Households Projected to be Served			0	0
	* Calculated by dividing the planned number of unit months occupied/leased by 12. ** In instances when a local, non-traditional program provides a certain subsidy level but does not specify a number of units/households to be served, the PHA should estimate the number of households to be served. ***Unit Months Occupied/Leased is the total number of months the PHA has leased/occupied units, according to unit category during the fiscal year.
	Reporting Compliance with Statutory MTW Requirements
	If the PHA has been out of compliance with any of the required statutory MTW requirements listed in Section II(C) of the Standard MTW Agreement, the PHA will provide a narrative discussion and a plan as to how it will return to compliance. If the PHA is currently in compliance, no discussion or reporting is necessary.
	Narrative description and explanation (if applicable)
	Description of any Anticipated Issues Related to Leasing of Public Housing, Housing Choice Vouchers and/or Local, Non-Traditional Units and Possible Solutions
	Housing Program Description of Anticipated Leasing Issues and Possible Solutions
	Housing Program 1		Description of specific leasing issues and possible solutions (if applicable)
	Housing Program 2		Description of specific leasing issues and possible solutions (if applicable)
	Housing Program 3		Description of specific leasing issues and possible solutions (if applicable)

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OMB Control Number: 2577-0216 Expiration Date: 5/31/2016

II.3.Plan.WaitList

C. MTW Plan: Wait List Information

Wait List Information Projected for the Beginning of the Fiscal Year

Housing Program(s) * Wait List Type**

Number of Households on Wait List

Wait List Open, Partially Open or Closed***

Are There Plans to Open the Wait List During the Fiscal Year

Wait List Type

Number of
Households

Wait List Type

Number of
Households

Number of
Households

Wait List Type

Open, Partially Open or Closed	Yes or No
Open, Partially	Yes or No
Open or Closed
Open, Partially	Yes or No
Open or Closed

Housing Program(s)

Housing Program(s)

Housing Program(s)

Rows for additional waiting lists may be added, if needed.

* Select Housing Program: Federal MTW Public Housing Units; Federal MTW Housing Choice Voucher Program; Federal non-MTW Housing Choice Voucher Units; Tenant-Based Local, Non-Traditional MTW Housing Assistance Program; Project-Based Local, Non-Traditional MTW Housing Assistance Program; and Combined Tenant-Based and Project-Based Local, Non-Traditional MTW Housing Assistance Program.

** Select Wait List Types: Community-Wide, Site-Based, Merged (Combined Public Housing or Voucher Wait List), Program Specific (Limited by

HUD or Local PHA Rules to Certain Categories of Households which are Described in the Rules for Program Participation), None (If the Program is a New Wait List, Not an Existing Wait List), or Other (Please Provide a Brief Description of this Wait List Type).

*** For Partially Open Wait Lists, provide a description of the populations for which the waiting list is open.

Housing Program and Description of the populations for which the wait list is open

Housing Program and Description of the populations for which the wait list is open

Housing Program and Description of the populations for which the wait list is open

If Local, Non-Traditional Housing Program, please describe:

Name and Description of "Local, Non-Traditional" Housing Program

Name and Description of "Local, Non-Traditional" Housing Program

Name and Description of "Local, Non-Traditional" Housing Program

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OMB Control Number: 2577-0216 Expiration Date: 5/31/2016

If Other Wait List Type, please describe:

Name and Description of "other" wait list type

Name and Description of "other" wait list type

Name and Description of "other" wait list type

If there are any changes to the organizational structure of the wait list or policy changes regarding the wait list, provide a narrative detailing these changes.

Narrative of changes

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OMB Control Number: 2577-0216 Expiration Date: 5/31/2016

Annual MTW Report

II.4.Report.HousingStock

A. MTW Report: Housing Stock Information

New Housing Choice Vouchers that were Project-Based During the Fiscal Year
Anticipated Actual Number Number of New of New Vouchers Property Name Description of Project Vouchers to be that were Project‑ Project-Based * Based
Property Name		X		X	Description of project 1
Property Name		X		X	Description of project 2
Property Name		X		X	Description of project 3
Property Name		X		X	Description of project 4
Anticipated Total Number of Anticipated Total Number of Project‑ Project-Based Vouchers Based Vouchers Leased Up or Issued Committed at the End of the to a Potential Tenant at the End of the Fiscal Year * Fiscal Year *
Actual Total Anticipated Total Number of New Number of New Vouchers that Vouchers to be were Project‑ Project-Based * Based						X	X
	0			0	Actual Total Number of Actual Total Number of Project-Based Project-Based Vouchers Vouchers Leased Up or Issued to a Committed at the End of the Potential Tenant at the End of the Fiscal Fiscal Year Year
						X	X
* From the Plan

Other Changes to the Housing Stock that Occurred During the Fiscal Year

Description of other changes to the housing stock during the fiscal year

Description of other changes to the housing stock during the fiscal year

Description of other changes to the housing stock during the fiscal year

Examples of the types of other changes can include but are not limited to units that are held off-line due to the relocation of residents, units that are off-line due to substantial rehabilitation and potential plans for acquiring units.

General Description of Actual Capital Fund Expenditures During the Plan Year

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OMB Control Number: 2577-0216 Expiration Date: 5/31/2016

Narrative general description of actual capital fund expenditures during the Plan year (by development)

Housing Program * Total Units Overview of the Program

Overview of the program

Overview of the program

Overview of the program

* Select Housing Program from: Tax-Credit, State Funded, Locally Funded, Market-Rate, Non-MTW HUD Funded, Managing Developments for other non-MTW Public Housing Authorities, or Other.

If Other, please describe:

Description of "other" Housing Program

Housing Program 1 *

Housing Program 2 *

Housing Program 3 *

Total Other Housing Owned
and/or Managed

X

X

X

0

Overview of Other Housing Owned and/or Managed by the PHA at Fiscal Year End

II.5.Report.Leasing

B. MTW Report: Leasing Information

Actual Number of Households Served at the End of the Fiscal Year
Number of Households Served* Housing Program: Planned Actual
Number of Units that were Occupied/Leased through Local Non-Traditional MTW Funded Property-Based Assistance Programs **	X	X
Number of Units that were Occupied/Leased through Local Non-Traditional MTW Funded Tenant-Based Assistance Programs **	X	X
Port-In Vouchers (not absorbed)	N/A	X
Total Projected and Actual Households Served	0	0
* Calculated by dividing the planned/actual number of unit months occupied/leased by 12. ** In instances when a Local, Non-Traditional program provides a certain subsidy level but does not specify a number of units/Households Served, the PHA should estimate the number of Households served.

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OMB Control Number: 2577-0216 Expiration Date: 5/31/2016

Unit Months Occupied/Leased****

Housing Program:

Households Served through Local Non-Traditional Services Only

X X

Planned Actual

Number of Units that were Occupied/Leased through Local Non-Traditional MTW Funded Property-Based Assistance Programs ***

Number of Units that were Occupied/Leased through Local Non-Traditional MTW Funded Tenant-Based Assistance Programs ***

Port-In Vouchers (not absorbed)

Total Projected and Annual Unit Months Occupied/Leased

Explanation for differences between planned and actual households served

*** In instances when a local, non-traditional program provides a certain subsidy level but does not specify a number of units/Households Served, the PHA should estimate the number of households served.

**** Unit Months Occupied/Leased is the total number of months the housing PHA has occupied/leased units, according to unit category during the year.

X

X

N/A

0

X

X

X

0

Average Number of Households Served Per

Month

Total Number of Households Served During the Year

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OMB Control Number: 2577-0216 Expiration Date: 5/31/2016

Reporting Compliance with Statutory MTW Requirements: 75% of Families Assisted are Very Low-Income

HUD will verify compliance with the statutory objective of “assuring that at least 75 percent of the families assisted by the Agency are very low-income families” is being achieved by examining public housing and Housing Choice Voucher family characteristics as submitted into the PIC or its successor system utilizing current resident data at the end of the agency's fiscal year. The PHA will provide information on local, non-traditional families provided with housing assistance at the end of the PHA fiscal year, not reported in PIC or its successor system, in the following format:

Fiscal Year:	2011	2012	2013	2014	2015	2016	2017	2018
Total Number of Local, Non‑ Traditional MTW Households Assisted	X	X	X	X	X	X	X	X
Number of Local, Non-Traditional MTW Households with Incomes Below 50% of Area Median Income	X	X	X	X	X	X	X	X
Percentage of Local, Non-Traditional MTW Households with Incomes Below 50% of Area Median Income	X	X	X	X	X	X	X	X

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OMB Control Number: 2577-0216 Expiration Date: 5/31/2016

Reporting Compliance with Statutory MTW Requirements: Maintain Comparable Mix

In order to demonstrate that the statutory objective of “maintaining a comparable mix of families (by family size) are served, as would have been provided had the amounts not been used under the demonstration” is being achieved, the PHA will provide information in the following formats:

Baseline for the Mix of Family Sizes Served

Family Size:	Occupied Number of Public Housing units by Household Size when PHA Entered MTW	Utilized Number of Section 8 Vouchers by Household Size when PHA Entered MTW	Non-MTW Adjustments to the Distribution of Household Sizes *	Baseline Number of Household Sizes to be Maintained	Baseline Percentages of Family Sizes to be Maintained
1 Person	X	X	X	X	X
2 Person	X	X	X	X	X
3 Person	X	X	X	X	X
4 Person	X	X	X	X	X
5 Person	X	X	X	X	X
6+ Person	X	X	X	X	X
Totals	0	0	0	0	0

Explanation for Baseline Adjustments to the Distribution of Household Sizes Utilized

Provide narrative with explanation

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Mix of Family Sizes Served

	1 Person	2 Person	3 Person	4 Person	5 Person	6+ Person	Totals
Baseline Percentages of Household Sizes to be Maintained **	X	X	X	X	X	X	0
Number of Households Served by Family Size this Fiscal Year ***	X	X	X	X	X	X	0
Percentages of Households Served by Household Size this Fiscal Year ****	X	X	X	X	X	X	0
Percentage Change	#VALUE!	#VALUE!	#VALUE!	#VALUE!	#VALUE!	#VALUE!	#DIV/0!

Justification and Explanation for Family Size Variations of Over 5% from the Baseline Percentages

Provide narrative with explanation

* “Non-MTW adjustments to the distribution of family sizes” are defined as factors that are outside the control of the PHA. Acceptable “non-MTW adjustments” include, but are not limited to, demographic changes in the community’s population. If the PHA includes non-MTW adjustments, HUD expects the explanations of the factors to be thorough and to include information substantiating the numbers used.

** The numbers in this row will be the same numbers in the chart above listed under the column “Baseline percentages of family sizes to be maintained.”

*** The methodology used to obtain these figures will be the same methodology used to determine the “Occupied number of Public Housing units by family size when PHA entered MTW” and “Utilized number of Section 8 Vouchers by family size when PHA entered MTW” in the table immediately above.

**** The “Percentages of families served by family size this fiscal year” will reflect adjustments to the mix of families served that are directly due to decisions the PHA has made. HUD expects that in the course of the demonstration, PHAs will make decisions that may alter the number of families served.

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OMB Control Number: 2577-0216 Expiration Date: 5/31/2016

Description of any Issues Related to Leasing of Public Housing, Housing Choice Vouchers or Local, Non-Traditional Units and Solutions

at Fiscal Year End

Housing Program Description of Leasing Issues and Solutions

Housing Program 1

Housing Program 2

Housing Program 3

Description of specific leasing issues and possible solutions (if applicable)

Description of specific leasing issues and possible solutions (if applicable)

Description of specific leasing issues and possible solutions (if applicable)

Activity Name/#	Number of Households Transitioned *	Agency Definition of Self Sufficiency
Activity Name/#	Number of Households Transitioned *	Agency Definition of Self Sufficiency
Activity Name/#	Number of Households Transitioned *	Agency Definition of Self Sufficiency
Activity Name/#	Number of Households Transitioned *	Agency Definition of Self Sufficiency
Activity Name/#	Number of Households Transitioned *	Agency Definition of Self Sufficiency

Households Duplicated Across Activities/Definitions	X	* The number provided here should match the outcome reported where metric SS #8 is used.
ANNUAL TOTAL NUMBER OF HOUSEHOLDS TRANSITIONED TO SELF SUFFICIENCY	#VALUE!

Number of Households Transitioned To Self-Sufficiency by Fiscal Year End

II.6.Report.Leasing

C. MTW Report: Wait List Information

Wait List Information at Fiscal Year End

Housing Program(s) * Wait List Type **

Number of Households on Wait List

Wait List Open, Partially Open or Closed ***

Was the Wait List Opened During the Fiscal Year

Wait List Type

Number of
Households

Wait List Type

Number of
Households

Number of
Households

Wait List Type

Open, Partially Open or Closed	Yes or No
Open, Partially	Yes or No
Open or Closed
Open, Partially	Yes or No
Open or Closed

Housing Program(s)

Housing Program(s)

Housing Program(s)

More can be added if needed.

* Select Housing Program: Federal MTW Public Housing Units; Federal MTW Housing Choice Voucher Program; Federal non-MTW Housing Choice Voucher Units; Tenant-Based Local, Non-Traditional MTW Housing Assistance Program; Project-Based Local, Non-Traditional MTW Housing Assistance Program; and Combined Tenant-Based and Project-Based Local, Non-Traditional MTW Housing Assistance Program.

** Select Wait List Types: Community-Wide, Site-Based, Merged (Combined Public Housing or Voucher Wait List), Program Specific (Limited by HUD or Local PHA Rules to Certain Categories of Households which are Described in the Rules for Program Participation), None (If the Program is a New Wait List, Not an Existing Wait List), or Other (Please Provide a Brief Description of this Wait List Type).

*** For Partially Open Wait Lists, provide a description of the populations for which the waiting list is open.

Housing Program and Description of the populations for which the wait list is open

Attachment B

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OMB Control Number: 2577-0216 Expiration Date: 5/31/2016

Housing Program and Description of the populations for which the wait list is open

Housing Program and Description of the populations for which the wait list is open

If Local, Non-Traditional Program, please describe:

Name and Description of "Local, Non-Traditional" Housing Program

Name and Description of "Local, Non-Traditional" Housing Program

Name and Description of "Local, Non-Traditional" Housing Program

If Other Wait List Type, please describe:

Name and Description of "other" wait list type

Name and Description of "other" wait list type

Name and Description of "other" wait list type

If there are any changes to the organizational structure of the wait list or policy changes regarding the wait list, provide a narrative detailing these changes.

Narrative of Changes

Attachment B

20

OMB Control Number: 2577-0216 Expiration Date: 5/31/2016

Form 50900: Elements for the Annual MTW Plan and Annual MTW Report

Attachment B

(III) Proposed MTW Activities: HUD approval requested

Annual MTW Plan

All required elements below must be put in the body of the Plan grouped by each MTW activity.

For metrics information, PHAs must follow the guidelines from the "Standard HUD Metrics" section of this Form

50900. PHAs must report all applicable metrics for each activity.

Required Elements for Proposed Activities in the MTW Plan:

Activity Description

1. Describe each proposed MTW activity;

2. Describe how each proposed activity will achieve one or more of the three statutory objectives;

3. Identify and discuss the anticipated impact of each proposed MTW activity on the stated objective(s); and

4. Provide the anticipated schedules for achieving the stated objective(s).

Activity Metrics Information

5. Provide the metric(s) from the "Standard HUD Metrics" section that will be used to quantify the changes that the PHA anticipates as a result of the MTW activity;

6. Give the baseline performance level for each metric (a numeric value) prior to the implementation of the MTW activity;

7. Give the yearly benchmarks for each metric (a numeric value);

8. Describe the final projected outcome(s) of the MTW activity for each metric; and

9. Give the data source from which metric data will be compiled.

Need/Justification for MTW Flexibility

10. Cite the authorization(s) detailed in Attachment C or D of the Standard MTW Agreement that gives the PHA the flexibility to conduct the activity;

11. Explain why the cited authorization from Attachment C or D is needed to engage in this activity;

Every reasonable effort will be made by the agency to reference the complete and correct authorizations from Attachment C or D that are applicable to a particular activity when proposing the activity. A failure to cite the correct or entire statute or regulation will require a technical revision to the activity to include the correct authorization from Attachment C or D of the agency's Standard MTW Agreement.

Attachment B

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OMB Control Number: 2577-0216 Expiration Date: 5/31/2016

Additional Information for Rent Reform Activities (if applicable)

L. Provide the following information for all rent reform activities: Impact Analysis, Hardship Case Criteria, Annual Reevaluation of Rent Reform Activity and Transition Period. HUD defines rent reform as any change in the regulations on how rent is calculated for a household. Any policy that an MTW PHA enacts that alters the rent calculation would be considered a type of rent reform and will require an impact analysis.

• Impact Analysis: To assess the impacts of the rent reform activity, four steps are suggested for conducting an

impact analysis, including:

1. A description of the rent reform activity;

2. Tracking and documenting the implementation of the rent reform activity;

1. Identifying the intended and possible unintended impacts (including changes to the amount of rent residents pay) of the rent reform activity; and

4. Measuring the impacts of the rent reform activity.

Ideally, a separate impact analysis would be completed for each individual component of the rent reform activity, so the agency is able to measure the actual impact of each component of the overall activity. However, in some cases, it may make more sense to complete an analysis for the aggregate of all rent reform activities, e.g., if the agency implements biennial recertifications for working households and triennial recertifications for elderly/disabled households.

• Hardship Case Criteria: MTW PHAs that implement rent reform activities should establish a hardship policy to

define circumstances under which households may be exempted or temporarily waived from the new rent determination rules.

• Description of Annual Reevaluation of Rent Reform Activity: MTW PHAs should provide an overview as to how

they will reevaluate rent reform activities on a yearly basis and revise as necessary to mitigate the negative impacts of unintended consequences.

• Transition Period: MTW PHAs shall develop a plan for transitioning residents out of the current rent structure

and into a new rent structure.

*For additional information on these issues, the PHA can reference the MTW Office website.

Required Elements for Proposed Activities in the MTW Report:

Section III in the Report will be included and left blank. However, PHAs should include a placeholder stating, "All proposed activities that are granted approval by HUD are reported on in Section IV as 'Approved Activities'.”

Attachment B

22

OMB Control Number: 2577-0216 Expiration Date: 5/31/2016

Form 50900: Elements for the Annual MTW Plan and Annual MTW Report

Attachment B

(IV) Approved MTW Activities: HUD approval previously granted

All required elements below must be put in the body of the Plan/Report grouped by each MTW activity.

For metrics information, PHAs must follow the guidelines from the "Standard HUD Metrics" section of this Form 50900. PHAs must report all applicable metrics for each activity.

Annual MTW Plan

Annual MTW Report

A. IMPLEMENTED ACTIVITIES

1. List approved, implemented, ongoing activities continued from the prior Plan year(s) that are actively utilizing flexibility from the MTW Agreement; specify the Plan Year in which the activity was first approved and implemented;

2. Provide a description of the activity and an update on its status;

1. List approved, implemented, ongoing activities continued from the prior Plan year(s); that are actively utilizing flexibility from the MTW Agreement; specify the Plan Year in which the activity was first approved and implemented;

2. Provide a description of the activity and detailed information on its impact. Compare outcomes to baselines and benchmarks, and indicate whether the activity is on schedule;

3. Indicate if the PHA anticipates any non­significant changes or modifications to the activity during the Plan year;

4. Indicate if the PHA anticipates any changes or modifications to the metrics, baselines or benchmarks during the Plan year;

i. For rent reform activities, describe the number and results of any hardship requests;

3. If benchmarks were not achieved or if the activity was determined ineffective, provide a narrative explanation of the challenges, and, if possible, identify potential new strategies that might be more effective;

5. If the PHA requires a different authorization from Attachment C or D when implementing the activity than was initially proposed, the PHA must re-propose the activity and include all required elements in Section (III) Proposed Activities; and

4. If benchmarks or metrics have been revised, identify original indicator(s) and new indicator(s) of activities status and impact; and

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OMB Control Number: 2577-0216 Expiration Date: 5/31/2016

6. HUD requires PHAs to re-propose activities that require a "significant change." A "significant change" occurs when the nature of the activity has changed such that an additional MTW authorization is needed or when a PHA fundamentally changes the nature and scope of an activity to the extent that there is the potential for a different impact on residents (e.g. changing the calculation of rent). In these cases a new public process is needed for residents to have the opportunity to be informed about the changes to the activity. HUD reserves the right to determine on a case-by-case basis if the change made to an activity crosses this threshold and therefore requires the activity to be re-proposed.	If data collection methodology has changed, describe original data collection methodology and any revisions to the process or change in data collected.
B. NOT YET IMPLEMENTED ACTIVITIES
1. Describe any approved activities that were proposed in the Plan, approved by HUD, but have not yet been implemented, and discuss why these activities were not implemented; specify the Plan Year in which the activity was first approved;	1. List any approved activities that were proposed in the Plan, approved by HUD, but not implemented; specify the Plan Year in which the activity was first approved; and
2. Provide an update on the plan for implementation of the activity;	Discuss any actions taken toward implementation during the fiscal year.
Provide a timeline for implementation;
Provide an explanation of any non-significant changes or modifications to the activity since it was approved;

Attachment B

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OMB Control Number: 2577-0216 Expiration Date: 5/31/2016

C. ACTIVITIES ON HOLD
1. Describe any approved activities that have been implemented that the PHA has stopped implementing but has plans to reactivate in the future; specify the Plan Year in which the activity was first approved, implemented, and placed on hold;	1. Describe any approved activities that have been implemented and the PHA has stopped implementing but has plans to reactivate in the future; specify the Plan Year in which the activity was first approved, implemented, and placed on hold; and
2. Discuss why these activities have been placed on hold;	Report any actions that were taken towards reactivating the activity.
Provide an update on the plan for reactivating the activity;
Provide a timeline for re-implementation; and
Provide an explanation of any non-significant changes or modifications to the activity since it was approved.
D. CLOSED OUT ACTIVITIES
1. List any approved activities that have been closed out, including activities that have never been implemented, that the PHA does not plan to implement and obsolete activities; specify the Plan Year in which the activity was first approved and implemented (if applicable);	1. List all approved activities that have been closed out, including activities that have never been implemented, that the PHA does not plan to implement and obsolete activities; specify the Plan Year in which the activity was first approved and implemented (if applicable);
2. Explain why these activities were closed out; and	Provide the year the activity was closed out; and
Provide the year the activity was closed out.	3. In the year the activity was closed out provide the following:
	Discuss the final outcome and lessons learned;
	Describe any statutory exceptions outside of the current MTW flexibilities that might have provided additional benefit for this activity;
	Provide a summary table, listing outcomes from each year of the activity (since the execution of the Standard MTW Agreement); and
	Provide a narrative for additional explanations about outcomes reported in the summary table.

Attachment B

25

OMB Control Number: 2577-0216 Expiration Date: 5/31/2016

Form 50900: Elements for the Annual MTW Plan and Annual MTW Report

Attachment B

(V) Sources and Uses of Funds

Annual MTW Plan

V.1.Plan.Sources and Uses of MTW Funds

A. MTW Plan: Sources and Uses of MTW Funds

Estimated Sources of MTW Funding for the Fiscal Year

PHAs shall provide the estimated sources and amounts of MTW funding by FDS line item.

Sources
FDS Line Item	FDS Line Item Name	Dollar Amount
70500 (70300+70400)	Total Tenant Revenue	$ X
70600	HUD PHA Operating Grants	$ X
70610	Capital Grants	$ X
70700 (70710+70720+70730+70740+70750)	Total Fee Revenue	$ X
71100+72000	Interest Income	$ X
71600	Gain or Loss on Sale of Capital Assets	$ X
71200+71300+71310+71400+71500	Other Income	$ X
70000	Total Revenue	0

Attachment B

26

OMB Control Number: 2577-0216 Expiration Date: 5/31/2016

Estimated Uses of MTW Funding for the Fiscal Year
	PHAs shall provide the estimated uses and amounts of MTW spending by FDS line item.
	Uses
	FDS Line Item	FDS Line Item Name	Dollar Amount
	91000 (91100+91200+91400+91500+91600+91700+91800+91900)	Total Operating - Administrative	$ X
	91300+91310+92000	Management Fee Expense	$ X
	91810	Allocated Overhead	$ X
	92500 (92100+92200+92300+92400)	Total Tenant Services	$ X
	93000 (93100+93600+93200+93300+93400+93800)	Total Utilities	$ X
	93500+93700	Labor	$ X
	94000 (94100+94200+94300+94500)	Total Ordinary Maintenance	$ X
	95000 (95100+95200+95300+95500)	Total Protective Services	$ X
	96100 (96110+96120+96130+96140)	Total insurance Premiums	$ X
	96000 (96200+96210+96300+96400+96500+96600+96800)	Total Other General Expenses	$ X
	96700 (96710+96720+96730)	Total Interest Expense and Amortization Cost	$ X
	97100+97200	Total Extraordinary Maintenance	$ X
	97300+97350	Housing Assistance Payments + HAP Portability-In	$ X
	97400	Depreciation Expense	$ X
	97500+97600+97700+97800	All Other Expenses	$ X
	90000	Total Expenses	0
Describe the Activities that Will Use Only MTW Single Fund Flexibility
	PHAs shall provide a thorough narrative of each activity that uses only the Single Fund Flexibility in the body of the Plan. In the narrative, PHAs are encouraged to provide metrics to track the outcomes of these programs or activities. Activities that use other MTW waivers in addition to Single Fund Flexibility do not need to be described in this section because descriptions of these activities are found in either Section (III) Proposed MTW Activities or Section (IV) Approved MTW Activities.

Attachment B

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OMB Control Number: 2577-0216 Expiration Date: 5/31/2016

V.2.Plan.Local Asset Management Plan

Is the PHA allocating costs within statute?	Yes	or	No
Is the PHA implementing a local asset management plan (LAMP)?	Yes	or	No

If the PHA is implementing a LAMP, it shall be described in an appendix every year beginning with the year it is proposed and approved. The narrative shall explain the deviations from existing HUD requirements and should be updated if any changes are made to the LAMP.

Has the PHA provided a LAMP in the appendix?

Yes

or

No

PHAs should provide a brief summary of any changes in the Local Asset Management Plan in the body of the Plan.

B. MTW Plan: Local Asset Management Plan

Annual MTW Report

V.3.Report.Sources and Uses of MTW Funds

A. MTW Report: Sources and Uses of MTW Funds

Actual Sources and Uses of MTW Funding for the Fiscal Year

PHAs shall submit their unaudited and audited information in the prescribed FDS format through the Financial Assessment System - PHA (FASPHA), or its successor system

	Describe the Activities that Used Only MTW Single Fund Flexibility
	PHAs shall provide a thorough narrative of each activity that used only the Single Fund Flexibility in the body of the Report. In the narrative, PHAs are encouraged to provide metrics to track the outcomes of these programs or activities. Activities that use other MTW waivers in addition to Single Fund Flexibility do not need to be described in this section because descriptions of these activities are found in either Section (III) Proposed MTW Activities or Section (IV) Approved MTW Activities.

Attachment B

28

OMB Control Number: 2577-0216 Expiration Date: 5/31/2016

V.4.Report.Local Asset Management Plan
MTW Report: Local Asset Management						Plan
If and	made Has the PHA allocated costs within statute during the plan year? Has the PHA implemented a local asset management plan (LAMP)? the PHA is implementing a LAMP, it shall be described in an appendix every approved. It shall explain the deviations from existing HUD requirements to the LAMP. Has the PHA provided a LAMP in the appendix?				or or		with the year it is proposed updated if any changes are
				Yes		No
				Yes		No
				year and		beginning should be
				Yes		No
	In the body of the Report, PHAs should provide a narrative updating the progress of implementing and operating the Local Asset Management Plan during the fiscal year.
V.5.Report.Unspent MTW Funds
MTW Report: Commitment of Unspent Funds
In the		table below, provide planned commitments or obligations of unspent MTW funds at the end of the PHA's fiscal year.
		Account	Planned Expenditure			Obligated Funds		Committed Funds
		Type	Description			$ X		$ X
		Type	Description			$ X		$ X
		Type	Description			$ X		$ X
		Type	Description			$ X		$ X
		Type	Description			$ X		$ X
		Type	Description			$ X		$ X
		Type	Description			$ X		$ X
		Type	Description			$ X		$ X
		Total Obligated or Committed Funds:				0		0
		In the body of the Report, PHAs shall provide, in as much detail as possible, an explanation of plans for future uses of unspent funds, including what funds have been obligated or committed to specific projects.
		Note: Written notice	of a definition of MTW reserves will be forthcoming. Until HUD issues a methodology for including a definition of obligations and commitments, MTW agencies are not required to complete this section.
		defining reserves,

Attachment B

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OMB Control Number: 2577-0216 Expiration Date: 5/31/2016

Form 50900: Elements for the Annual MTW Plan and Annual MTW Report Attachment B
(VI) Administrative
The PHA shall provide the information below with the first Plan/Report submittal to HUD.
Annual MTW Plan Annual MTW Report
A. Resolution signed by the Board of Commissioners, or other authorized PHA official if there is no Board of Commissioners, adopting the Annual MTW Plan Certification of Compliance (provided at the end of this Attachment B);	A. General description of any HUD reviews, audits or physical inspection issues that require the agency to take action to address the issue;
B. The beginning and end dates of when the Annual MTW Plan was made available for public review, the dates, locations of public hearings and total number of attendees for the draft Annual MTW Plan, (to ensure PHAs have met the requirements for public participation, HUD reserves the right to request additional information to verify PHAs have complied with all requirements as set forth in the Standard MTW Areement	Results of latest PHA-directed evaluations of the demonstration, as applicable; and
Description of any planned or ongoing PHA- directed evaluations of the demonstration for the overall MTW program or any specific MTW activities, if applicable; and	C. Certification that the PHA has met the three statutory requirements of: 1) assuring that at least 75 percent of the families assisted by the Agency are very low-income families; 2) continuing to assist substantially the same total number of eligible low-income families as would have been served had the amounts not been combined; and 3) maintaining a comparable mix of families (by family size) are served, as would have been provided had the amounts not been used under the demonstration.
D. The Annual Statement/Performance and Evaluation Report (HUD 50075.1) or subsequent form required by HUD for MTW and non-MTW Capital Fund grants for each grant that has unexpended amounts, including estimates for the Plan Year and all three parts of the report;

Attachment B

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OMB Control Number: 2577-0216 Expiration Date: 5/31/2016

Form 50900: Elements for the Annual MTW Plan and Annual MTW Report

Attachment B

Certifications of Compliance

Annual Moving to Work Plan U.S. Department of Housing and Urban Development

Certifications of Compliance Office of Public and Indian Housing

Certifications of Compliance with Regulations:

Board Resolution to Accompany the Annual Moving to Work Plan*

Acting on behalf of the Board of Commissioners of the Public Housing Agency (PHA) listed below, as its Chairman or other authorized PHA official if there is no Board of Commissioners, I approve the submission of the Annual Moving to Work Plan for the PHA fiscal year

beginning , hereinafter referred to as "the Plan", of which this document is a part and make the following certifications and agreements with the Department of Housing and Urban Development (HUD) in connection with the submission of the Plan and implementation thereof:

1. The PHA published a notice that a hearing would be held, that the Plan and all information relevant to the public hearing was available for public inspection for at least 30 days, that there were no less than 15 days between the public hearing and the approval of the Plan by the Board of Commissioners, and that the PHA conducted a public hearing to discuss the Plan and invited public comment.

2. The PHA took into consideration public and resident comments (including those of its Resident Advisory Board or Boards) before approval of the Plan by the Board of Commissioners or Board of Directors in order to incorporate any public comments into the Annual MTW Plan.

3. The PHA certifies that the Board of Directors has reviewed and approved the budget for the Capital Fund Program grants contained in the Capital Fund Program Annual Statement/Performance and Evaluation Report, form HUD-50075.1.

4. The PHA will carry out the Plan in conformity with Title VI of the Civil Rights Act of 1964, the Fair Housing Act, section 504 of the Rehabilitation Act of 1973, and title II of the Americans with Disabilities Act of 1990.

5. The Plan is consistent with the applicable comprehensive housing affordability strategy (or any plan incorporating such strategy) for the jurisdiction in which the PHA is located.

6. The Plan contains a certification by the appropriate State or local officials that the Plan is consistent with the applicable Consolidated Plan, which includes a certification that requires the preparation of an Analysis of Impediments to Fair Housing Choice, for the PHA's jurisdiction and a description of the manner in which the PHA Plan is consistent with the applicable Consolidated Plan.

7. The PHA will affirmatively further fair housing by examining its programs or proposed programs, identify any impediments to fair housing choice within those programs, address those impediments in a reasonable fashion in view of the resources available and work with local jurisdictions to implement any of the jurisdiction's initiatives to affirmatively further fair housing that require the PHA's involvement and maintain records reflecting these analyses and actions.

8. The PHA will comply with the prohibitions against discrimination on the basis of age pursuant to the Age Discrimination Act of 1975.

9. The PHA will comply with the Architectural Barriers Act of 1968 and 24 CFR Part 41, Policies and Procedures for the Enforcement of Standards and Requirements for Accessibility by the Physically Handicapped.

10. The PHA will comply with the requirements of section 3 of the Housing and Urban Development Act of 1968, Employment Opportunities for Low-or Very-Low Income Persons, and with its implementing regulation at 24 CFR Part 135.

11. The PHA will comply with requirements with regard to a drug free workplace required by 24 CFR Part 24, Subpart F.

12. The PHA will comply with requirements with regard to compliance with restrictions on lobbying required by 24 CFR Part 87, together with disclosure forms if required by this Part, and with restrictions on payments to influence Federal Transactions, in accordance with the Byrd Amendment and implementing regulations at 49 CFR Part 24.

Attachment B

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OMB Control Number: 2577-0216 Expiration Date: 5/31/2016

13. The PHA will comply with acquisition and relocation requirements of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 and implementing regulations at 49 CFR Part 24 as applicable.

14. The PHA will take appropriate affirmative action to award contracts to minority and women's business enterprises under 24 CFR 5.105( a).

15. The PHA will provide HUD or the responsible entity any documentation needed to carry out its review under the National Environmental Policy Act and other related authorities in accordance with 24 CFR Part 58. Regardless of who acts as the responsible entity, the PHA will maintain documentation that verifies compliance with environmental requirements pursuant to 24 Part 58 and 24 CFR Part 50 and will make this documentation available to HUD upon its request.

16. With respect to public housing the PHA will comply with Davis-Bacon or HUD determined wage rate requirements under section 12 of the United States Housing Act of 1937 and the Contract Work Hours and Safety Standards Act.

17. The PHA will keep records in accordance with 24 CFR 85.20 and facilitate an effective audit to determine compliance with program requirements.

18. The PHA will comply with the Lead-Based Paint Poisoning Prevention Act and 24 CFR Part 35.

19. The PHA will comply with the policies, guidelines, and requirements of OMB Circular No. A-87 (Cost Principles for State, Local and Indian Tribal Governments) and 24 CFR Part 85 (Administrative Requirements for Grants and Cooperative Agreements to State, Local and Federally Recognized Indian Tribal Governments).

20. The PHA will undertake only activities and programs covered by the Plan in a manner consistent with its Plan and will utilize covered grant funds only for activities that are approvable under the Moving to Work Agreement and Statement of Authorizations and included in its Plan.

21. All attachments to the Plan have been and will continue to be available at all times and all locations that the Plan is available for public inspection. All required supporting documents have been made available for public inspection along with the Plan and additional requirements at the primary business office of the PHA and at all other times and locations identified by the PHA in its Plan and will continue to be made available at least at the primary business office of the PHA.

PHA Name PHA Number/HA Code

I hereby certify that all the information stated herein, as well as any information provided in the accompaniment herewith, is true and accurate. Warning: HUD will prosecute false claims and statements. Conviction may result in criminal and/or civil penalties. (18 U.S.C. 1001, 1010, 1012; 31 U.S.C. 3729, 3802)

Name of Authorized Official Title

Signature Date

*Must be signed by either the Chairman or Secretary of the Board of the PHA's legislative body. This certification cannot be signed by an employee unless authorized by the PHA Board to do so. If this document is not signed by the Chairman or Secretary, documentation such as the by-laws or authorizing board resolution must accompany this certification.

Attachment B

32

OMB Control Number: 2577-0216 Expiration Date: 5/31/2016

Form 50900: Elements for the Annual MTW Plan and Annual MTW Report

Attachment B

Standard HUD Metrics

For all activities in Section (III) Proposed Activities and activities in Section (IV) Approved Activities in the "Implemented" category, the PHA must use all of the applicable standard metrics listed below for each statutory objective cited. Standard metrics must be reported in the table format provided in order to allow analysis and aggregation across PHAs for similar activities.

For standard metrics that are different from the metrics the PHA had been reporting on for an implemented activity, the PHA may set a baseline prior to when the activity began (through historical records or extrapolation from available data). If such information is not available, the PHA may set the baseline in the Annual MTW Report where the standard metric is first presented. If one of the standard metrics had not been used in previous Annual MTW Reports, the PHA must begin tracking the activity using the standard metrics during the current fiscal year.

PHAs should show the component variables that comprise figures (for example, in showing a "Total Cost," a PHA would show the cost per transaction and number of transactions).

PHAs have the flexibility to report on agency developed and previously established metrics in addition to the required standard metrics.

Cost Effectiveness

When citing the statutory objective to “reduce cost and achieve greater cost effectiveness in federal expenditures,” include all of the following metrics that apply:

CE #1: Agency Cost Savings
Unit of Measurement	Baseline	Benchmark	Outcome	Benchmark Achieved?
Total cost of task in dollars (decrease).	Cost of task prior to implementation of the activity (in dollars).	Expected cost of task after implementation of the activity (in dollars).	Actual cost of task after implementation of the activity (in dollars).	Whether the outcome meets or exceeds the benchmark.

CE #2: Staff Time Savings
Unit of Measurement	Baseline	Benchmark	Outcome	Benchmark Achieved?
Total time to complete the task in staff hours (decrease).	Total amount of staff time dedicated to the task prior to implementation of the activity (in hours).	Expected amount of total staff time dedicated to the task after implementation of the activity (in hours).	Actual amount of total staff time dedicated to the task after implementation of the activity (in hours).	Whether the outcome meets or exceeds the benchmark.

CE #3: Decrease in Error Rate of Task Execution
Unit of Measurement	Baseline	Benchmark	Outcome	Benchmark Achieved?
Average error rate in completing a task as a percentage (decrease).	Average error rate of task prior to implementation of the activity (percentage).	Expected average error rate of task after implementation of the activity (percentage).	Actual average error rate of task after implementation of the activity (percentage).	Whether the outcome meets or exceeds the benchmark.

CE #4: Increase in Resources Leveraged
Unit of Measurement	Baseline	Benchmark	Outcome	Benchmark Achieved?
Amount of funds leveraged in dollars (increase).	Amount leveraged prior to implementation of the activity (in dollars). This number may be zero.	Expected amount leveraged after implementation of the activity (in dollars).	Actual amount leveraged after implementation of the activity (in dollars).	Whether the outcome meets or exceeds the benchmark.

Attachment B

33

OMB Control Number: 2577-0216 Expiration Date: 5/31/2016

CE #5: Increase in Agency Rental Revenue
Unit of Measurement	Baseline	Benchmark	Outcome	Benchmark Achieved?
Rental revenue in dollars (increase).	Rental revenue prior to implementation of the activity (in dollars).	Expected rental revenue after implementation of the activity (in dollars).	Actual rental revenue after implementation of the activity (in dollars).	Whether the outcome meets or exceeds the benchmark.

Self Sufficiency

When citing the statutory objective to “give incentives to families...whose heads of household are either working, seeking work, or are participating in job training educational or other programs to assist in obtaining employment and becoming economically self-sufficient,” include all of the following metrics that apply:

SS #1: Increase in Household Income
Unit of Measurement	Baseline	Benchmark	Outcome	Benchmark Achieved?
Average earned income of households affected by this policy in dollars (increase).	Average earned income of households affected by this policy prior to implementation of the activity (in dollars).	Expected average earned income of households affected by this policy prior to implementation of the activity (in dollars).	Actual average earned income of households affected by this policy prior to implementation (in dollars).	Whether the outcome meets or exceeds the benchmark.

SS #2: Increase in Household Savings
Unit of Measurement	Baseline	Benchmark	Outcome	Benchmark Achieved?
Average amount of savings/escrow of households affected by this policy in dollars (increase).	Average savings/escrow amount of households affected by this policy prior to implementation of the activity (in dollars). This number may be zero.	Expected average savings/escrow amount of households affected by this policy after implementation of the activity (in dollars).	Actual average savings/escrow amount of households affected by this policy after implementation of the activity (in dollars).	Whether the outcome meets or exceeds the benchmark.

SS #3: Increase in Positive Outcomes in Employment Status
Report the Baseline, Benchmark and Outcome data for each type of employment status for those head(s) of households affected by the self-sufficiency activity.
Unit of Measurement	Baseline	Benchmark	Outcome	Benchmark Achieved?
Report the following information separately for each category: Employed Full- Time Employed Part- Time Enrolled in an Educational Program Enrolled in Job Training Program Unemployed Other	Head(s) of households in <<category name>> prior to implementation of the activity (number). This number may be zero.	Expected head(s) of households in <<category name>> after implementation of the activity (number).	Actual head(s) of households in <<category name>> after implementation of the activity (number).	Whether the outcome meets or exceeds the benchmark.
	Percentage of total work-able households in <<category name>> prior to implementation of activity (percent). This number may be zero.	Expected percentage of total work-able households in <<category name>> after implementation of the activity (percent).	Actual percentage of total work-able households in <<category name>> after implementation of the activity (percent).	Whether the outcome meets or exceeds the benchmark.

Attachment B

34

OMB Control Number: 2577-0216 Expiration Date: 5/31/2016

SS #4: Households Removed from Temporary Assistance for Needy Families (TANF)
Unit of Measurement	Baseline	Benchmark	Outcome	Benchmark Achieved?
Number of households receiving TANF assistance (decrease).	Households receiving TANF prior to implementation of the activity (number)	Expected number of households receiving TANF after implementation of the activity (number).	Actual households receiving TANF after implementation of the activity (number).	Whether the outcome meets or exceeds the benchmark.

SS #5: Households Assisted by Services that Increase Self Sufficiency
Unit of Measurement	Baseline	Benchmark	Outcome	Benchmark Achieved?
Number of households receiving services aimed to increase self sufficiency (increase).	Households receiving self sufficiency services prior to implementation of the activity (number).	Expected number of households receiving self sufficiency services after implementation of the activity (number).	Actual number of households receiving self sufficiency services after implementation of the activity (number).	Whether the outcome meets or exceeds the benchmark.

SS #6: Reducing Per Unit Subsidy Costs for Participating Households
Unit of Measurement	Baseline	Benchmark	Outcome	Benchmark Achieved?
Average amount of Section 8 and/or 9 subsidy per household affected by this policy in dollars (decrease).	Average subsidy per household affected by this policy prior to implementation of the activity (in dollars).	Expected average subsidy per household affected by this policy after implementation of the activity (in dollars).	Actual average subsidy per household affected by this policy after implementation of the activity (in dollars).	Whether the outcome meets or exceeds the benchmark.

SS #7: Increase in Agency Rental Revenue
Unit of Measurement	Baseline	Benchmark	Outcome	Benchmark Achieved?
PHA rental revenue in dollars (increase).	PHA rental revenue prior to implementation of the activity (in dollars).	Expected PHA rental revenue after implementation of the activity (in dollars).	Actual PHA rental revenue after implementation of the activity (in dollars).	Whether the outcome meets or exceeds the benchmark.

SS #8: Households Transitioned to Self Sufficiency
Unit of Measurement	Baseline	Benchmark	Outcome	Benchmark Achieved?
Number of households transitioned to self sufficiency (increase). The PHA may create one or more definitions for "self sufficiency" to use for this metric. Each time the PHA uses this metric, the "Outcome" number should also be provided in Section (II) Operating Information in the space provided.	Households transitioned to self sufficiency (<<PHA definition of self-sufficiency>>) prior to implementation of the activity (number). This number may be zero.	Expected households transitioned to self sufficiency (<<PHA definition of self-sufficiency>>) after implementation of the activity (number).	Actual households transitioned to self sufficiency (<<PHA definition of self-sufficiency>>) after implementation of the activity (number).	Whether the outcome meets or exceeds the benchmark.

Attachment B

35

OMB Control Number: 2577-0216 Expiration Date: 5/31/2016

Housing Choice

When citing the statutory objective to “increase housing choices for low-income families,” include all of the following metrics that apply:

HC #1: Additional Units of Housing Made Available
Unit of Measurement	Baseline	Benchmark	Outcome	Benchmark Achieved?
Number of new housing units made available for households at or below 80% AMI as a result of the activity (increase). If units reach a specific type of household, give that type in this box.	Housing units of this type prior to implementation of the activity (number). This number may be zero.	Expected housing units of this type after implementation of the activity (number).	Actual housing units of this type after implementation of the activity (number).	Whether the outcome meets or exceeds the benchmark.

HC #2: Units of Housing Preserved
Unit of Measurement	Baseline	Benchmark	Outcome	Benchmark Achieved?
Number of housing units preserved for households at or below 80% AMI that would otherwise not be available (increase). If units reach a specific type of household, give that type in this box.	Housing units preserved prior to implementation of the activity (number).	Expected housing units preserved after implementation of the activity (number).	Actual housing units preserved after implementation of the activity (number).	Whether the outcome meets or exceeds the benchmark.

HC #3: Decrease in Wait List Time
Unit of Measurement	Baseline	Benchmark	Outcome	Benchmark Achieved?
Average applicant time on wait list in months (decrease).	Average applicant time on wait list prior to implementation of the activity (in months).	Expected average applicant time on wait list after implementation of the activity (in months).	Actual average applicant time on wait list after implementation of the activity (in months).	Whether the outcome meets or exceeds the benchmark.

HC #4: Displacement Prevention
Unit of Measurement	Baseline	Benchmark	Outcome	Benchmark Achieved?
Number of households at or below 80% AMI that would lose assistance or need to move (decrease). If units reach a specific type of household, give that type in this box.	Households losing assistance/moving prior to implementation of the activity (number).	Expected households losing assistance/moving after implementation of the activity (number).	Actual households losing assistance/moving after implementation of the activity (number).	Whether the outcome meets or exceeds the benchmark.

HC #5: Increase in Resident Mobility
Unit of Measurement	Baseline	Benchmark	Outcome	Benchmark Achieved?
Number of households able to move to a better unit and/or neighborhood of opportunity as a result of the activity (increase).	Households able to move to a better unit and/or neighborhood of opportunity prior to implementation of the activity (number). This number may be zero.	Expected households able to move to a better unit and/or neighborhood of opportunity after implementation of the activity (number).	Actual increase in households able to move to a better unit and/or neighborhood of opportunity after implementation of the activity (number).	Whether the outcome meets or exceeds the benchmark.

HC #6: Increase in Homeownership Opportunities
Unit of Measurement	Baseline	Benchmark	Outcome	Benchmark Achieved?
Number of households that purchased a home as a result of the activity (increase).	Number of households that purchased a home prior to implementation of the activity (number). This number may be zero.	Expected number of households that purchased a home after implementation of the activity (number).	Actual number of households that purchased a home after implementation of the activity (number).	Whether the outcome meets or exceeds the benchmark.

Attachment B

36

OMB Control Number: 2577-0216 Expiration Date: 5/31/2016

HC #7: Households Assisted by Services that Increase Housing Choice
Unit of Measurement	Baseline	Benchmark	Outcome	Benchmark Achieved?
Number of households receiving services aimed to increase housing choice (increase).	Households receiving this type of service prior to implementation of the activity (number). This number may be zero.	Expected number of households receiving these services after implementation of the activity (number).	Actual number of households receiving these services after implementation of the activity (number).	Whether the outcome meets or exceeds the benchmark.

Attachment B

37

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Mussington, Arlette A
File Modified	0000-00-00
File Created	2021-01-21