50058 MTW Expansion Family Report

OMB Approval Number 2577-0083 (expires xx/xx/xxxx)

U.S. Department of Housing and
Urban Development
Office of Public and Indian Housing

Family Report

Form HUD-50058-MTW Expansion Family Report applies to Public Housing and Housing
Choice Voucher programs.

form HUD-50058 MTW Expansion (xx/xxxx)

Public reporting burden for this collection of information is estimated to average 40 minutes per response in the first year and 20
minutes per response in subsequent years. This estimate includes the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. This agency may not collect this
information, and you are not required to complete this Form, unless it displays a currently valid OMB control number.
Privacy Act Information. This collection is authorized by the U. S. Housing Act of 1937 (42 U. S. C. 1437 et seq.), Title VI of the
Civil Rights Act of 1964 (42 U. S. C. 2000d) and by the Fair Housing Act (42 U. S. C. 3601-19). Each affected agency must submit
information to assist HUD in managing and monitoring HUD assisted housing programs, to protect the Government's interest,
and to verify the accuracy of the information received. The information requested is required to obtain or retain benefits. Failure to
provide SSN could result in denial of eligibility and/or termination of assistance or tenancy participants. HUD is authorized to collect this
information under the Housing and Community Development Act of 1987 42 U.S.C.3543 (a).
Purpose of this information collection:

Analyze assisted housing programs;

Determine the occupancy level of public housing and calculate the operating subsidy in accordance with 24 CFR 990;

Permit PHAs to monitor their own reporting to identify favorable and unfavorable trends;

Monitor PHAs and participants for compliance with program regulations and requirements;

Fraud detection and prevention via rent/income monitoring;

Housing inventory and development of program initiatives with emphasis on the housing of special needs groups; and

Make available accurate demographic information depicting tenant characteristics to Congress and other interested parties.
Sensitive Information: The information on these forms is sensitive and is protected by the Privacy Act. Keep the forms locked and
confidential.
Acronyms
FMR = Fair Market Rent
FSS = Family Self-Sufficiency program
HAP = Housing Assistance Payment
HQS = Housing Quality Standards
HUD = U. S. Department of Housing and Urban Development
ISA = Individual Savings Account
OMB = U. S. Office of Management and Budget
PHA = Public Housing Agency
PHRA = Public Housing Reform Act

PIC = Public and Indian Housing Information Center
SRO = Single Room Occupancy
SSA = Social Security Administration
SSI = Supplemental Security Income
SSN = Social Security Number
TANF = Temporary Assistance for Needy Families
TIN = Taxpayer Identification Number
TTP = Total Tenant Payment

Major Definitions (refer to the Form HUD-50058 Instruction Booklet for a more detailed definition of fields on the
Form that are unchanged from the Form HUD-50058 MTW Expansion):
Disabilities: A person with disabilities has one or more of the following: (a) a disability as defined in Section 223 of the
Social Security Act, (b) a physical, mental, or emotional impairment which is expected to be of long-continued and
indefinite duration, substantially impedes his or her ability to live independently, and is of such a nature that such ability
could be improved by more suitable housing conditions, or (c) a developmental disability as defined in Section 102 of the
Developmental Disabilities Assistance and Bill of Rights Act. Note: Include persons who have the acquired immune
deficiency syndrome (AIDS) or any condition that arises from the etiologic agent for AIDS.
Effective Date of Action: Date the reported action becomes effective. The effective date cannot be earlier than the
date of admission to the program.
Head of household: The one adult member of the household, designated by the family or by PHA policy as the
head of household, who is wholly or partly responsible for the rent payment.
Mixed Family: A family that contains some members that are eligible for assistance and some members that are
ineligible for assistance. This family may be subject to prorated rent under the Noncitizens Rule.
Portability: Renting a dwelling unit with Housing Choice Voucher assistance outside the jurisdiction of the initial PHA.
Form Conventions:
1. All fields that require the entry of a date must include the 4-digit year. Enter the date in a standard format (i. e., "mm/dd/yyyy",
"mm/yyyy"). Enter the year in its entirety.
2. "/" means "or" unless otherwise noted.
3. Monetary figures: enter only whole dollar amounts. Do not show cents, commas, or dollar signs.
4. Rounding: round each monetary amount up when a number is 0.50 or above; down when a number is 0.49 or below.
5. Calculation column is a scratch area where PHAs may perform manual calculations.
6. Leave blank any line(s) or item(s) that do not apply unless this Form instructs otherwise.

i

form HUD-50058 MTW Expansion (xx/xxxx)

Head of household name

Social Security Number

Family Report

Date modified (mm/dd/yyyy)

U.S. Department of Housing and Urban Development

OMB Approval Number 2577-0083

Office of Public and Indian Housing

1. Agency
1a. Agency name
1b. PHA code
1c. Program

P = Public Housing, T = Tenant-Based Assistance, PR = Project-Based Assistance
H = Homeownership, LP = Local, Non-Traditional Property-Based Vouchers, LN = Local,
Non-Traditional Tenant-Based

1d. Project Number (Public Housing only)
1e. Building Number (Public Housing only)
1f. Building Entrance Number (Public Housing only)
1g. Unit Number (Public Housing only)
1h. Unit Real Estate ID Number (see page ii)

1a.
1b.
1c.
1d.
1e.
1f.
1g.
1h.

2. Action
2a.
2b.
2c.
2d.

Type of Action
Effective date (mm/dd/yyyy) of action
Correction? (Y or N)
If correction: (check primary reason)

2a.
2b.
2c.
[ ] Family correction of income [ ] Family correction (non-income)
[ ] PHA correction of family income [ ] PHA correction (non-income)

2h. Date (mm/dd/yyyy) of admission to program
2i. Projected effective date (mm/dd/yyyy) of next reexamination
2j. Projected date (mm/dd/yyyy) of next flat rent annual update (Public Housing flat rent only)
2k. FSS participation now or in the last year? (Y or N)
2m. Special program: (vouchers only) (check only one)
[ ] Enhanced Voucher
2n. Other special programs: Number 01
2n. Other special programs: Number 02
2q. PHA use only
2r. PHA use only
2s. PHA use only
2t. PHA use only
2u. PHA use only
2v. MTW self-sufficiency program participation now or in last year? (Y or N)
2w. End of Participation reasons (only if 2a = End Participation)
2x. Interim Reexamination reasons (only if 2a = Interim Reexamination)
2a. Type of action codes
1 = New Admission
2 = Full Reexamination
3 = Interim Reexamination
4 = Portability Move-in (VO only)
5 = Portability Move-out (VO only)
6 = End Participation
7 = Other Change of Unit
8 = FSS/MTW Self-Sufficiency
Addendum Only
9 = Annual Reexamination Searching
(VO only)
10 = Issuance of Voucher (VO only)
11 = Expiration of Voucher (VO only)
12 = Flat Rent Annual Update (PH
only)
13 = Annual HQS Inspection Only
(VO only)
15 = Void

2w. End of Participation reasons
1. Changed program (non-RAD)
2. Changed program due to RAD
conversion
3. Unit uninhabitable
4. Death of sole family member
5. Absence from unit
6. Evicted by landlord
7. Terminated by PHA because family is
over-income (Public Housing) or exceeds
180 days of zero HAP (HCV)
8. Reached term limit
9. Failed to comply with work requirement
10. PHA initiated EOP for reasons other
than codes 4-9 (i.e. violation of program
rules, lost eligibility, etc.)
11. Financial situation has improved and no
longer need subsidy
12. Dissatisfied with subsidized housing
13. Tenant initiated EOP for reasons other
than codes 11-12

2

2h.
2i.
2j.
2k.
2n.
2n.
2q.
2r.
2s.
2t.
2u.
2v.
2w.
2x.

2x. Interim Reexamination reasons
1. Alternative rent hardship request
2. Stepped rent update without income reexamination
3. Decreased income (not an alternative rent hardship
request)
4. Increased income
5. Household composition change
6. Contract rent change

form HUD-50058 MTW Expansion (xx/xxxx)

Note:
Head of
household
name:
Social
Security
Number
Date
modified
(mm/dd/yyyy)
1:
Line 1a:
Line 1b:
Note:
Line 1c:
Line 1d:
Line 1e:
Line 1f:
Line 1g:
Line 1h:
2:
Line 2a:
Note:
Line 2b:
Note:
Line 2c:
Note:
Line 2d:
Line 2h:
Line 2i:
Line 2j:
Line 2k:
Line 2m:
Line 2n:
Note:
Line 2q-2u:
Line 2v:
Note:
Line 2w:
Line 2x:

Page Heading
The fields in the page heading are provided for the convenience of PHA that maintain paper records of the
Form HUD-50058.
On every page, enter the head of household’s last name (line 3b), first name (line 3c) and middle initial
(line 3d). Use this field to identify the head of household if the pages of the Form separate.
On every page, enter the head of household’s Social Security Number (line 3n). Use this field to identify
the head of household if the pages of the Form separate.
On every page, ender the date the PHA representative completes the Form.

Agency
Name of the Public Housing Agency (PHA) that completes the family's Form HUD-50058.
Five-character code composed of the 2-letter postal state code and 3-digit PHA number. The state code indicates
the location of the reporting PHA and the number identifies each PHA within a particular state.
For help obtaining the PHA's identification number, contact the appropriate HUD field office.
Using the codes provided, indicate the housing assistance program in which the family participates. Note that
H = Homeownership is for traditional homeownership vouchers, not Local, Non-Traditional Homeownership.
The Local Non-Traditional Homeownership program is not applicable in the MTW expansion.
Public Housing only. The project number is composed of the 2-letter project state code, 3-digit PHA
number, and 6-digit development number (if applicable).
Public Housing only. Six-character code to capture the tenant's building number.
Public Housing only. Three-character code to capture the building's entrance number.
Public Housing only. Ten-character code to capture the PHA designated tenant unit number.
Unit Real Estate ID Number established by the system for the unit. Currently Public Housing only; may be
used for other programs in the future.
Action
Use the codes provided at the bottom of the page to report the family's type of action.
When a family that receives flat rent requires a full reexamination, use Annual Reexamination (2a= 2).
Date the reported action becomes effective.
The effective date cannot be earlier than the date of admission to the program (line 2h).
Allows PHAs to correct fields previously transmitted in error.
Use a correction for a minor change to a previously submitted record.
Indicate the primary reason for the correction record.
Date the PHA initially admitted the family into the program reported in line 1c.
The projected effective date of the family's next reexamination.
Public Housing flat rent only. Projected effective date of the next flat rent annual update.
Indicate if the family currently participates or participated in the Family Self-Sufficiency program in the
past year.
Housing Choice Vouchers only. Indicate if the family receives an Enhanced Voucher.
Indicate if the family participates in a special program.
See Form HUD-50058 Instruction Booklet for a listing of special programs and their abbreviations.
PHAs may use these lines for any information they wish to collect.
Indicate if the family currently participates or participated in an MTW self-sufficiency program in the past year.
HUD encourages PHAs to use lines 2q through 2u for local initiatives.
If line 2a is End Participation, indicate the reason the family ended their participation in the program
If line 2a is Interim Reexamination, indicate the reason there has been a change to the family’s information at a
time other than a full reexamination or change of unit.

ii

form HUD-50058 MTW Expansion (xx/xxxx)

Head of household name

Social Security Number

Date modified (mm/dd/yyyy)

3. Household
3a. Head of
Household
Member number
01

3b. Last name & Sr., Jr. etc.
3g. Sex

3h. Relation
H
3n. Social Security Number

3c. First name
3i. Citizenship

3d. MI

3e. Date of birth

3j. Disability (Y or N)

3f. Age on effective
date of action
3m. Ethnicity

3k. Race
[ ] 1. [ ] 2. [ ] 3. [ ] 4. [ ] 5.
3p. Alien Registration Number
3q. Meeting community service or selfAsufficiency requirement? (PH only)

3r. Average number of hours worked per week
3a. Member
number 02

3b. Last name & Sr., Jr. etc.
3g. Sex

3h. Relation

3c. First name
3i. Citizenship

3d. MI

3e. Date of birth

3j. Disability (Y or N)

3f. Age on effective
date of action
3m. Ethnicity

3k. Race
[ ] 1. [ ] 2. [ ] 3. [ ] 4. [ ] 5.
3p. Alien Registration Number
3q. Meeting community service or selfAsufficiency requirement? (PH only)

3n. Social Security Number
3r. Average number of hours worked per week
3a. Member
number 03

3b. Last name & Sr., Jr. etc.
3g. Sex

3h. Relation

3c. First name
3i. Citizenship

3d. MI

3e. Date of birth

3j. Disability (Y or N)

3f. Age on effective
date of action
3m. Ethnicity

3k. Race
[ ] 1. [ ] 2. [ ] 3. [ ] 4. [ ] 5.
3p. Alien Registration Number
3q. Meeting community service or selfAsufficiency requirement? (PH only)

3n. Social Security Number
3r. Average number of hours worked per week
3a. Member
number 04

3b. Last name & Sr., Jr. etc.
3g. Sex

3h. Relation

3c. First name
3i. Citizenship

3d. MI

3e. Date of birth

3j. Disability (Y or N)

3f. Age on effective
date of action
3m. Ethnicity

3k. Race
[ ] 1. [ ] 2. [ ] 3. [ ] 4. [ ] 5.
3p. Alien Registration Number
3q. Meeting community service or selfAsufficiency requirement? (PH only)

3n. Social Security Number
3r. Average number of hours worked per week
3a. Member
number 05

3b. Last name & Sr., Jr. etc.
3g. Sex

3h. Relation

3c. First name
3i. Citizenship

3d. MI

3e. Date of birth

3j. Disability (Y or N)

3f. Age on effective
date of action
3m. Ethnicity

3k. Race
[ ] 1. [ ] 2. [ ] 3. [ ] 4. [ ] 5.
3p. Alien Registration Number
3q. Meeting community service or selfAsufficiency requirement? (PH only)

3n. Social Security Number
3r. Average number of hours worked per week
3a. Member
number 06

3b. Last name & Sr., Jr. etc.
3g. Sex

3h. Relation

3c. First name
3i. Citizenship

3d. MI

3e. Date of birth

3j. Disability (Y or N)

3f. Age on effective
date of action
3m. Ethnicity

3k. Race
[ ] 1. [ ] 2. [ ] 3. [ ] 4. [ ] 5.
3p. Alien Registration Number
3q. Meeting community service or selfAsufficiency requirement? (PH only)

3n. Social Security Number
3r. Average number of hours worked per week
3a. Member
number 07

3b. Last name & Sr., Jr. etc.
3g. Sex

3h. Relation

3c. First name
3i. Citizenship

3d. MI

3j. Disability (Y or N)

3e. Date of birth

3f. Age on effective
date of action
3m. Ethnicity

3k. Race
[ ] 1. [ ] 2. [ ] 3. [ ] 4. [ ] 5.
3p. Alien Registration Number
3q. Meeting community service or selfAsufficiency requirement? (PH only)

3n. Social Security Number
3r. Average number of hours worked per week

3s. Work requirement compliance
3t. Total number in household
3u. Family subsidy status under Noncitizens Rule
3v. Eligibility effective date (mm/dd/yyyy) if qualified for continuation of full assistance (3u=C)
3w. If new head of household, former head of household’s SSN
3h. Relation codes:
H = head
S = spouse
K = co-head
F = foster child/foster Adult
Y = other youth under 18
E = full-time student 18+
L = live-in aide
A = other adult
3i. Citizenship codes:
EC = eligible citizen
EN = eligible noncitizen
IN = ineligible noncitizen
PV = pending verification

3k. Race codes:
1 = White
2 = Black/African American
3 = American Indian/Alaska Native
4 = Asian
5 = Native Hawaiian/Other Pacific Islander

3s.
3t.
3u.
3v.
3w.
3r. Average number of hours worked per week codes:
1 = 0 hours
2 = 1-10 hours/week
3 = 11- 20 hours/week
4 = 21-30 hours /week
5 = 31-40 hours/week
6 = More than 40 hours/week

3m. Ethnicity codes:
1 = Hispanic or Latino
2 = not Hispanic or Latino
3q. Community service or self-sufficiency codes:
1 = yes
2 = no
3 = pending
4 = exempt

3s. Work requirement compliance codes:
1 = In compliance
2 = Exempt
3 = Receiving a hardship
4 = Not in compliance, in probationary period and not subject to penalties
5 = Not in compliance, subject to penalties
6 = Not applicable, no work requirement policy
3u. Family subsidy status codes:
C = qualified for continuation of full assistance
E = eligible for full assistance
F = eligible for full assistance pending verification of status
P = prorated assistance

3

form HUD-50058 MTW Expansion (xx/xxxx)

3.
Note:
Note:
Note:

Line 3a:
Line 3b:
Line 3c:
Line 3d:
Line 3e:
Line 3f:
Line 3g:
Line 3h:
Line 3i:
Line 3j:
Line 3k:
Line 3m:
Line 3n:
Note:
Line 3p:
Note:

Line 3q:
Note:
Line 3r:
Line 3s:
Line 3t:
Note:

Line 3u:

Note:
Line 3v:
Line 3w:

Household
Complete for each household member.
The first family member (member number 01) must be the head of household.
The household includes everyone who lives in the unit. Household members are used to determine unit size.
The family includes all household members except live-in aides and foster children and foster adults. Family
members are used to calculate subsidies and payments.
The member number identifies the individual listed on that line of the Form.
The last name of each household member. Include name suffixes, such as Jr., and separate with a comma. Do
not include name prefixes, such as Ms. or Mr.
The first name of each household member. Do not include name prefixes, such as Ms. or Mr.
The middle initial of each household member. If no middle initial, leave blank. If more than one middle initial,
only enter one.
The date of birth for each household member.
The age in years of each household member on the effective date of action (line 2b).
Indicate the gender of each household member.
Select the code at bottom of the page that best categorizes the relation or role of each household member.
Select the code at the bottom of page that indicates each household member's United States citizenship status.
Indicate whether or not the household member has a disability.
Select the code or codes at the bottom of the page that the family says best indicates each household
member's race. Select as many codes as appropriate.
Select the code at bottom of page and check the box next to the code the family says best indicates each
household member's ethnicity.
Enter the 9-digit Social Security Number (SSN) issued to each household member by the Social Security
Administration (SSA).
If a head of household does not have a SSN, see the Form HUD-50058 Instruction Booklet.
Enter the Alien Registration Number or A-number issued to each noncitizen household member, if applicable.
The A-number contains seven, eight or nine numerical digits preceded by the letter A, e. g., A72 735 827. If the
A-number has seven digits, enter two zeros before the numbers. If the A-number has eight digits, enter one
zero before the numbers. If the A-number has nine digits, enter the number without a leading zero. Do not enter
the letter A in any case.
Public Housing only. Select the code at the bottom of the page to indicate whether the family member met his
or her community service or self-sufficiency requirement under PHRA.
The law requires an average of eight hours of community service per month during the year.
Average number of hours worked per week, over the past year.
State to what extent the household is in compliance with the PHA’s work requirements policy, if applicable.
The total number of people in the household.
Count all persons. Include foster children or adults, live-in aides, and other unrelated individuals (who reside
with the family as part of the household). Also include persons who are members of the household but
temporarily absent from the home.
Select the code on the bottom of the page that indicates the housing assistance eligibility for family members
based on the Noncitizens Rule. The Noncitizens Rule allows PHAs to provide financial assistance to U. S.
citizens, nationals, and non-U. S. citizens with eligible immigration status.
If the family's status under the Noncitizens Rule is prorated assistance (3u= P), the family should fill out the
applicable prorated rent calculation when determining rent burden.
Date the family originally qualified for the continuation of full assistance (3u= C).
If the designated head of household changed due to discontinued occupancy or other cause such as death,
marriage, or remarriage and there are family members who remain in the household, enter the former head of
household’s Social Security Number (SSN).

iii

form HUD-50058 MTW Expansion (xx/xxxx)

Head of household name

Social Security Number

Date modified (mm/dd/yyyy)

4. Background at Admission
4a.
4b.
4c.
4d.
4e.

Date (mm/dd/yyyy) entered waiting list
ZIP code before admission
Homeless at admission? (Y or N)
Does family qualify for admission over the very low-income limit? (HCV only) (Y or N)
Continuously assisted under the 1937 Housing Act? (Y or N)

4a.
4b.
4c.
4d.
4e.

5. Unit to be Occupied on Effective Date of Action
5a. Unit Address
Number and street
Apt.
City
State
ZIP code (+4)
5b. Is mailing address same as unit address? (Y or N) (if yes, skip to 5d)
5c. Family’s mailing address
Number and street
Apt.
City
State
ZIP code (+4)
5d. Number of bedrooms in unit
5e. Has the PHA identified this unit as an accessible unit? (Public Housing only) (Y or N)
5f. Has the family requested accessibility features? (Public Housing only) (Y or N) (if no, skip to next
section)
5g. Has the family received requested accessibility features? (Public Housing only)
[ ] a. Yes, fully [ ] b. Yes, partially [ ] c. No, not at all [ ] d. Action pending (can be checked in combination with b. or c.
5h. Date (mm/dd/yyyy) unit last passed HQS inspection (Section 8 only, except Homeownership and
Project-based Vouchers)
5i. Date (mm/dd/yyyy) of last HQS inspection (Section 8 only, except Homeownership and Project
based Vouchers)
5j. Year (yyyy) unit was built (Section 8 only)
5k. Structure type (check only one) (Section 8 only)
[ ] Single family detached
[ ] Semi-detached
[ ] Rowhouse/townhouse
[ ] Low-rise
[ ] High rise with elevator
[ ] Manufactured home

4

5b.

5d.
5e.
5f.

5h.
5i.
5j.

form HUD-50058 MTW Expansion (xx/xxxx)

4:

Background at Admission

Line 4a:

Date the PHA placed the family on the waiting list for the program under which they currently receive housing
assistance.
This date must not be later than effective date of action (line 2b).
The 5-digit ZIP code (+ 4, if applicable) where the family lived before admission to an assistance program.
Indicate whether or not the family was homeless at the time the PHA admitted the family to a housing
assistance program.
Vouchers only. Indicate whether or not the family qualified for program admission even though their income
exceeds the very low-income limit (50% of the area's median income).
Indicate whether or not the family is continuously assisted under or currently enrolled in any 1937 Housing Act
program at the time of admission.
Unit to be Occupied on Effective Date of Action
The complete address of the housing unit that the household occupies on the effective date of action (line 2b).
Indicate whether the mailing address is different from the unit address.
The complete address where the family receives mail, if other than the unit address provided in line 5a.
Leave this field blank if the mailing address is the same as the unit address.
Total number of bedrooms in the unit that the household will occupy on the effective date of action (line 2b).
Public Housing only. Indicate whether or not the unit that the family occupies on the effective date of action
(line 2b) is a PHA designated handicapped accessible unit.
Public Housing only. Indicate whether or not the family requested disability amenities or accessibility features.
Public Housing only. Indicate the status of the family's request for disability amenities and/or accessibility
features (line 5f) on the effective date of action (line 2b).
Section 8 only, except Homeownership and Project-based Vouchers. The last date the unit passed a full
housing quality standards (HQS) inspection.
Section 8 only, except Homeownership and Project-based Vouchers. The last date a PHA inspector
performed a full housing quality standards (HQS) inspection of the unit that the household occupies.
This date may be different from the date unit last passed HQS inspection (line 5h) if the unit failed the last
HQS inspection.
Section 8 only. The year that the unit was built.
This date is found on the request for tenancy approval form.
Section 8 only. The building structure type.
See the Instruction Booklet for descriptions of each housing type.

Note:
Line 4b:
Line 4c:
Line 4d:
Line 4e:
5:
Line 5a:
Line 5b:
Line 5c:
Note:
Line 5d:
Line 5e:
Line 5f:
Line 5g:
Line 5h:
Line 5i:
Note:
Line 5j:
Note:
Line 5k:
Note:

iv

form HUD-50058 MTW Expansion (xx/xxxx)

Head of household name

Social Security Number

Date modified (mm/dd/yyyy)

6. Assets
6a. Family Member Name

No.

6b.
Type
of
asset

6c. Calculation (PHA use)

6f, 6g. Column totals
6h. Passbook rate (written as decimal)
6i. Imputed asset income: 6f X 6h (if 6f is $5,000 or less, put 0)
6j. Final asset income: larger of 6g or 6i

6d. Cash value of
asset

6e. Anticipated
Income

$
$
$
$
$
$
$
$
$

$
$
$
$
$
$
$
$
$

6f.

6g.
6h.
6i.
6j.

7. Income
7a. Family Member Name

No.

7b.
Income
Code

7c. Calculation
(PHA use)

7g. Column total
7h. Prior year or current year/anticipated income
7i. Total annual income: 6j + 7g
7b. Income Codes
Wages:
B = own business
F = federal wage
HA = PHA wage
M = military pay
W = other wage

7d. Dollars per year

7e. Income
exclusions

7f. Income after
exclusions

$
$
$
$
$
$
$
$
$
$
$
$

$
$
$
$
$
$
$
$
$
$
$
$

(7d minus 7e)
$
$
$
$
$
$
$
$
$
$
$
$
$

[ ] Prior year

7g.

[ ] Current year/anticipated income

7i.

Welfare:
G = general assistance
IW = annual imputed welfare income
T = TANF assistance
SS/SSI/Pensions:
P = pension
S = SSI
SS = Social Security

5

Other Income Sources
C = child support
E = medical reimbursement
I = Indian trust/per capita
N = other nonwage sources
U = unemployment benefits

form HUD-50058 MTW Expansion (xx/xxxx)

6:
Note:
Line 6a:
Line 6b:
Note:
Line 6c:
Line 6d:
Line 6e:
Line 6f:
Line 6g:
Line 6h:
Note:
Line 6i:
Note:
Line 6j:
7:
Note:

Line 7a:
Line 7b:
Note:
Line 7c:
Line 7d:
Note:
Line 7e:
Note:
Note:
Line 7f:
Line 7g:
Line 7h:
Line 7i:

Assets
Use a separate line for each family member and asset type.
The name of each family member in the household that has assets and their Member number (line(s) 3a) that
corresponds to the asset information reported.
List any asset that has a dollar value or provides a source of income to the person listed in column 6a.
See the Form HUD-50058 Instruction Booklet for an explanation of allowable assets.
Use this column to perform asset calculations.
Estimated, known or calculated dollar value of the asset listed.
Total amount of income the family member expects to receive in the next 12-month period from the asset
listed.
Total of the values listed in column 6d.
Total of the values listed in column 6e.
Enter the passbook rate as a decimal.
The HUD field office determines the Passbook rate of interest for the project locality based on the average
interest rate received on a Passbook Savings Account at several banks in the local area.
Imputed income from assets based on the total dollar value of the asset listed and the Passbook rate of
interest.
If the total cash value of assets is $5,000 or less, enter 0.
Total amount of household income derived from assets.
Income
If the family members do not have any income from sources other than assets and do not expect any other
income in the next 12-month period, leave 7a through 7g blank. Fill in total annual income (line 7i), which
would be the total of the asset income.
The name of each family member in the household that has income and their Member number (line(s) 3a)
that corresponds to the income information reported.
Use one or two letter code at bottom of page that represents the type of income for a family member.
See the Form HUD-50058 Instruction Booklet for a detailed description of each income code.
Use this column to perform income calculations.
Yearly income amount the family member receives from the income source(s) listed.
See the Form HUD-50058 Instruction Booklet for a description of each income source.
Income excluded from annual income calculations.
Includes income disallowance and individual savings accounts (ISA) for Public Housing.
See the Form HUD-50058 Instruction Booklet for a description of each income exclusion.
The family's total income minus any exclusions. Take dollars per year (line 7d) minus income exclusions (line
7e).
The total of the dollar amounts listed in column 7f.
Indicate whether prior year or current/anticipated income has been entered in this section.
The family's total annual income. Add the final asset income (line 6j) and the total income after income
exclusions (line 7g).

v

form HUD-50058 MTW Expansion (xx/xxxx)

Head of household name

Social Security Number

Date modified (mm/dd/yyyy)

8. Deductions and Allowances
8a. Total annual income: copy from 7i
Permissible Deductions (Public Housing Only. If Section 8, Skip to 8f or 8q)
8b. Family Member Name
No.
8c. Type of permissible deduction

8e. Total permissible deductions (sum of column 8d)
If head/spouse/co-head is under 62 and no family member is disabled, skip to 8q
8f. Medical/disability threshold: 8a X 0.03
8g. Total annual unreimbursed disability assistance expense (if no disability expenses, skip to 8k)
8h. Maximum disability allowance: If 8g minus 8f is positive or zero, put amount
If negative and head/spouse/co-head is under 62 and not
disabled, put 0
If negative and head/spouse/co-head is elderly or disabled,
copy from 8g
8i. Earnings in 7d made possible by disability assistance expense
8j. Allowable disability assistance expense: lower of 8h or 8i (if 8g is less than 8f and head/spouse/co-head
elderly or disabled, copy from 8h)
8k. Total annual unreimbursed medical expenses (if head/spouse/co-head under 62 and not disabled, put 0)
8m. Total annual disability assistance and medical expense: 8j + 8k (if no disability expenses, copy from 8k)
8n. Medical/disability assistance
If no disability assistance expenses or if 8g is less than 8f, put
allowance:
8m minus 8f (if 8m minus 8f is negative, put zero)
If disability assistance expenses and 8g is greater than or equal
to 8f, copy from 8m
8p. Elderly/disability allowance (default = $400)
8q. Number of dependents (people under 18, or with disability, or full-time student. Do not count head of
household, spouse, co-head, foster child/adult, or live-in aide.)
8r. Allowance per dependent (default = $480)
8s. Dependent allowance: 8q X 8r
8t. Total annual unreimbursed childcare costs
8u. Deductions and allowances not reflected above (all programs; see page vi for more information)
8x. Total allowances: 8e + 8n + 8p + 8s + 8t + 8u (all programs)
8y. Adjusted annual income: 8a minus 8x (if 8x is larger, put 0)

6

$

8a.

8d. Amount
$
$
$
$
$
$
$

8e.

$
$
$
$

8f.
8g.
8h.
8h.

$

8h.

$
$

8i.
8j.

$
$
$

8k.
8m.
8n.

$

8n.

$
$

8p.
8q.

$
$
$
$
$
$

8r.
8s.
8t.
8u.
8x.
8y.

form HUD-50058 MTW Expansion (xx/xxxx)

8:
Line 8a:
Line 8b:
Line 8c:
Line 8d:
Line 8e:

Expected Income Per Year
The family's total annual family income. Copy from 7i.
Public Housing only. The name of each family member in the household, and their individual Member number
as provided in line(s) 3a that corresponds to the income information reported.
Public Housing only. The type of permissible deduction as determined by the PHA.
Public Housing only. The amount of the permissible deduction.
Public Housing only. The total of the dollar amounts (permissible deductions) listed in column 8d.

Note:

If the head of household and spouse or co-head are under age 62, and there are no family members with a
disability, skip to line 8q. Otherwise, enter all medical expense information for the entire family in lines 8f
through 8n.

Line 8f:

Amount of unreimbursed medical and disability expenses that the family must pay before the PHA can deduct
an allowance for such expenses from their income. Multiply 0.03 by total annual income (line 8a).
The family's total annual unreimbursed disability expenses.
The amount the PHA may potentially deduct for the family's disability expenses. Subtract the medical/
disability threshold (line 8f) from the total unreimbursed disability assistance expenses (line 8g).
If the maximum disability allowance is negative and head/spouse/co-head is under 62 and not disabled, enter
0.
If the maximum disability allowance is negative and head/spouse/co-head is elderly or disabled, copy the total
unreimbursed disability assistance expenses (line 8g).
Of a family's dollars per year listed in line 7d, determine the earned amount made possible by the
unreimbursed disability expenses the family incurs.
The total disability assistance expense amount the family may deduct. Lower of the maximum disability
allowance (line 8h) or the earnings made possible by disability assistance expense (line 8i).
If the total unreimbursed disability assistance expense (line 8g) is less than the medical/disability threshold
(line 8f), and head/spouse/co-head is elderly or disabled, copy the maximum disability allowance (line 8h).
The total annual amount of the family's medical expenses that another source does not reimburse (e. g., copayments for medical insurance).
If the head/spouse/co-head is under 62 and not disabled, enter 0.
The amount of the family's total disability assistance (line 8j) and medical expenses (line 8k).
If no disability expenses, copy the total unreimbursed medical expenses (line 8k).
The amount of the family's allowance for medical expenses and disability assistance expenses.
If the family does not have any disability assistance expenses or if the total unreimbursed disability assistance
expenses (line 8g) is less than the medical/disability threshold (line 8f), enter the total disability assistance
and medical expenses (line 8m) minus the medical/disability threshold (line 8f). If the difference is negative,
put zero.

Line 8g:
Line 8h:
Note:
Note:
Line 8i:
Line 8j:
Note:
Line 8k:
Note:
Line 8m:
Note:
Line 8n:
Note:

Note:

Line 8p:
Line 8q:
Line 8r:
Note:
Line 8s:
Line 8t:
Note:
Line 8u:

Line 8x:
Line 8y:
Note:

If disability assistance expense and the total unreimbursed disability assistance expense (line 8g) are greater
than or equal to the medical/disability threshold (line 8f), copy the total disability assistance and medical
expenses (line 8m).
The family's standard allowance amount if the head of household or spouse or co-head is elderly (age 62 or
over), or disabled. The current allowance is $400.
The total number of dependents who live in the household and are under 18 years of age, or have a disability,
or are full-time students of any age.
Standard allowance amount for each dependent in the household.
The current allowance per dependent is $480.
The amount of the family's dependent allowance. Multiply the number of dependents (line 8q) in the
household by the standard allowance per dependent amount (line 8r).
The household's total yearly unreimbursed childcare expenses.
This is the estimated amount a family expects to pay for childcare during the annual income period.
The total amount of deductions and allowances not reflected on other lines in this section. These would
include those covered in waivers per the MTW Operations Notice. Also, to be used for Local, Non-Traditional
Property-Based and Local, Non-Traditional Tenant-Based programs.
The total amount of all of the family's allowances. Enter the sum of lines 8e, 8n, 8p, 8s, 8t, and 8u.
The family's adjusted annual income. Subtract total allowances (line 8x) from total annual income (line 8a).
If 8u or 8x is larger, put 0.

vi

form HUD-50058 MTW Expansion (xx/xxxx)

Head of household name

Social Security Number

Date modified (mm/dd/yyyy)

9. Total Tenant Payment (TTP)
9a. Total monthly income: 8a ÷ 12
9c. TTP if based on annual income: 9a X 0.10
9d. Adjusted monthly income: 8y ÷ 12
9e. Percentage of adjusted monthly income: use 30% for vouchers
9f. TTP if based on adjusted annual income: (9d X 9e) ÷ 100
9g. Welfare rent per month (if none, put 0)
9h. Minimum rent (if waived, put 0)
9i. Enhanced Voucher minimum rent
9j. TTP, highest of lines 9c, 9f, 9g, 9h, or 9i
9k. Most recent TTP
9m. Qualify for minimum rent hardship exemption? (Y or N)

7

$
$
$
$
$
$
$
$
$
$
$

9a.
9c.
9d.
9e.
9f.
9g.
9h.
9i.
9j.
9k.
9m.

form HUD-50058 MTW Expansion (xx/xxxx)

9:
Line 9a:
Line 9c:
Line 9d:
Line 9e:
Note:
Line 9f:
Line 9g:

Note:
Line 9h:
Note:
Line 9i:
Line 9j:
Line 9k:
Note:
Line 9m:
Note:

Total Tenant Payment (TTP)
Divide total annual income (line 8a) by 12 to get total monthly income.
Multiply total monthly income (line 9a) by 0.10 to get total tenant payment (TTP) based on annual income.
Divide adjusted annual income (line 8y) by 12 to get adjusted monthly income.
Percentage of adjusted monthly income used to determine total tenant payment (TTP).
Use 30% for Section 8.
Multiply the adjusted monthly income (line 9d) by percentage of adjusted monthly income (line 9e) and divide
by 100 to get total tenant payment (TTP) based on adjusted monthly income.
The amount the welfare assistance agency specifically designates for shelter and utilities if the family receives
welfare assistance. The welfare assistance agency may adjust this amount in accordance with the actual cost
of shelter and utilities.
If no welfare rent, put 0.
Enter the PHA established monthly minimum rent amount. The PHA may require the tenant to pay a minimum
rent amount up to $50.
If the PHA waived this payment because of financial hardship, enter 0.
Enhanced Vouchers only. Enter the monthly rent that the family was paying on the date of the 'eligibility event'
for the project.
The total tenant payment (TTP). The highest amount listed in the lines 9c, 9f, 9g, 9h, or 9i.
The most recent total tenant payment (TTP) amount for the family.
This amount is only available if the family previously lived in subsidized housing.
Indicate if the family qualifies for a minimum rent hardship exemption.
Under PHRA, a family does not have to pay the PHA established minimum rent if they qualify for a financial
hardship exemption.

vii

form HUD-50058 MTW Expansion (xx/xxxx)

Head of household name

Social Security Number

Date modified (mm/dd/yyyy)

10. Public Housing
10a. TTP: copy from 9j
10b. Unit’s flat rent

$
$

10a.
10b.

$
$
$

10d.
10e.
10f.

$

10f.

$
$
$
$
$
$
$
$

10h.
10i.
10j.
10k.
10n.
10p.
10r.
10s.

$

10s.

Income Based Rent Calculation (if prorated rent, skip to 10h)
10d. Lower of TTP or flat rent (if no flat rent, put 10a)
10e. Utility allowance, if any
10f. Tenant rent: 10d minus 10e

If positive or 0, put tenant
rent
If negative, credit tenant

Income Based Prorated Rent Calculation (if not prorated, skip to 10u)
10h. Public Housing maximum rent
10i. Family maximum subsidy: 10h minus 10a
10j. Total number eligible
10k. Total number in family
10n. Eligible subsidy (10i ÷ 10k) X 10j
10p. Mixed family TTP: 10h minus 10n
10r. Utility allowance, if any
10s. Mixed family tenant rent: 10p minus 10r

If positive or 0, put tenant
rent
If negative, credit tenant

Type of Rent
10u. Type of rent selected:

[ ] Income-based
[ ] Over-income rent
[ ] MTW alternative gross income

[ ] Flat
[ ] MTW Stepped rent
[ ] MTW Tiered rent
[ ] MTW alternative adjusted income
[ ] Other MTW alternative rent

10v. Date over-income family exceeded the two-year grace period (if over-income rent was selected in 10u)
10w. Alternate tenant rent (if selection other than income-based or flat is
If positive or 0, put tenant
marked in 10u)
rent
If negative, credit tenant

8

$

10v.
10w.

$

10w.

form HUD-50058 MTW Expansion (xx/xxxx)

10:
Note:

Line 10a:
Line 10b:
Note:
Note:
Line 10d:
Note:
Line 10e:
Note:
Line 10f:
Line 10h:
Line 10i:
Line 10j:
Line 10k:
Note:
Line 10n:
Line 10p:
Line 10r:
Note:
Line 10s:
Line 10u:
Line 10v:
Note:
Line 10w:

Public Housing
Complete if the family participates in the Public Housing program (line 1c=P) and the type of action is New
Admission (2a= 1), Annual Reexamination (2a= 2), Interim Reexamination (2a= 3), or Other Change of Unit (2a=
7).
The total tenant payment (TTP). Copy from 9j.
Flat rent dollar amount.
Flat rent is set by the unit size and building.
See the Instruction Booklet for the prorated flat rent calculation.
The lesser amount of either the total tenant payment (TTP) (line 10a) or flat rent (line 10b).
If there is no flat rent, enter the TTP (line 10a).
If the payment does not include all utilities, the monthly allowance amount for tenant supplied utilities that apply
to the family occupied unit.
If there is no utility allowance, enter 0.
The rent amount the family pays to the owner after deducting the utility allowance (line 10e) from the lower rent
(line 10d) or the total credit amount the family receives to pay utilities.
The maximum rent. To calculate the maximum rent, list the total tenant payments (TTP) paid by all tenants in this
size unit in the PHA's jurisdiction from largest to smallest, then take the TTP that falls at the 95th percentile.
Maximum amount of rent subsidy available to the family. Subtract total tenant payment (TTP) (line 10a) from the
Public Housing maximum rent (line 10h).
The total number of family members eligible for rent subsidy based on the Noncitizens Rule.
The total number of family members in the household.
Include all family members, including ineligible noncitizen family members (3i= IN). Do not include live-in aides or
foster children/adults.
The total amount of rent subsidy for which the family is eligible. Divide family maximum subsidy (line 10i) by the
total number in the family (line 10k) and multiply the product by the total number eligible (line 10j).
The mixed family total tenant payment (TTP) for the unit based on the proration calculation. Public Housing
maximum rent (line 10h) minus eligible subsidy (line 10n).
If the payment does not include all utilities, the monthly allowance amount for tenant supplied utilities that apply
to the family occupied unit.
If there is no utility allowance, enter 0.
The rent amount the family pays to the owner after deducting the utility allowance (line 10r) from the mixed
family total tenant payment (TTP) (line 10p), or the total credit amount the family receives to pay for utilities.
Indicate whether the family selected an income-based rent, flat rent or one of the alternate rent types that are
listed. All alternate rent types except over-income are MTW specific per the MTW Operations Notice.
Indicate the date an over-income family exceeded the two-year grace period outlined in Housing Opportunity
Through Modernization Act of 2016 (HOTMA) and related guidance.
Line 10v should only be completed if over-income was selected in line 10u.
The rent amount the family pays when an alternate type of rent is selected in line 10u. If the amount is negative
due to a utility reimbursement, enter the negative amount and credit the family.

viii

form HUD-50058 MTW Expansion (xx/xxxx)

Head of household name

Social Security Number

Date modified (mm/dd/yyyy)

11. Housing Choice Voucher: Project-Based Vouchers and Local, Non-Traditional Property-Based
11b. Is family now moving to this unit? (Y or N)
11d. Did family move into your PHA jurisdiction under portability? (Y or N) (if no, skip to 11g)
11e. Cost billed per month (put 0 if absorbed)
11f. PHA code billed
11g. Housing type
[ ] Group Home (prorate gross rent) [ ] SRO: 1 room occupied by 1 person
11h. Owner name
11i. Owner TIN/SSN
11k. Contract rent to owner (if unit has other subsidy, put subsidized rent)
11m. Utility allowance, if any
11n. Gross rent of unit: 11k + 11m
11q. TTP: copy from 9j

$

11b.
11d.
11e.
11f.

$

$
$
$
$

11h.
11i.
11k.
11m.
11n.
11q.

$
$
$
$

11r.
11s.
11s.
11t.

Rent Calculation (if prorated rent, skip to 11aa)
11r. Total HAP: 11n minus 11q. If 11q is larger, put 0
11s. Tenant rent: 11k minus 11r
11t. HAP to owner: lower of 11k or 11r
11u. MTW specific alternate rent type:

If positive or 0, put tenant rent
If negative, credit tenant

[ ] MTW alternative gross income
[ ] MTW alternative adjusted income

[ ] MTW Stepped rent
[ ] MTW Tiered rent
[ ] Other MTW alternative rent

11v. Alternate HAP to owner (if a selection is made in 11u, including Local, Non-Traditional Property-Based
program)
11w. Alternate tenant rent (if a selection is made in 11u, including Local, Non-Traditional Property-Based
program)

$

11v.

$

11w.

$

11aa.
11ae.
11af.
11ag.
11ah.
11ai.
11aj.
11ak.
11ak.
11an.

Prorated Rent Calculation
11aa. Normal total HAP: 11n minus 11q
11ae. Total number eligible
11af. Total number in family
11ag. Proration percentage: 11ae ÷ 11af
11ah. Prorated total HAP: 11aa X 11ag
11ai. Mixed family TTP: 11n minus 11ah
11aj. Utility allowance: copy from 11m
11ak. Mixed family tenant rent: 11ai minus 11aj

If positive or 0, put tenant rent
If negative, credit tenant
11an. Prorated HAP to owner: 11k minus 11ak (if 11ak is negative, put 11k)
[ ] MTW alternative gross income
[ ] MTW Stepped rent
11ap. MTW specific alternate rent type:
[ ] MTW alternative adjusted income

[ ] MTW Tiered rent

[ ] Other MTW alternative rent

11aq. Alternate prorated HAP to owner (if a selection is made in 11ap, including Local, Non-Traditional
Property-Based program)
11ar. Alternate prorated tenant rent (if a selection is made in 11ap, including Local, Non-Traditional
Property-Based program)

9

$
$
$
$
$
$
$

11aq.

$

11ar.

form HUD-50058 MTW Expansion (xx/xxxx)

11:

Housing Choice Voucher: Project-Based Vouchers and Local, Non-Traditional Property-Based

Note:

Complete if the family participates in the Project Based Voucher program (1c= PR) or Local, Non-Traditional
Property-Based (1c = LP) and the type of action is New Admission (2a= 1), Annual Reexamination (2a= 2),
Interim Reexamination (2a= 3), Portability Move-in (2a= 4), or Other Change of Unit (2a= 7).
Indicate if the family is now moving into the unit.

Line 11b:
Line 11d:
Line 11e:
Note:
Line 11f:
Line 11g:
Line 11h:
Line 11i:
Line 11k:
Line 11m:
Line 11n:
Line 11q:
Line 11r:
Line 11s:
Line 11t:
Line 11u:
Line 11v:
Line 11w:
Line 11aa:
Line 11ae:
Line 11af:
Note:
Line 11ag:
Line 11ah:
Line 11ai:
Line 11aj:
Line 11ak:
Line 11an:
Note:
Line 11ap:
Line 11aq:

Line 11ar:

Indicate whether or not the household will move or has moved into the PHA's jurisdiction under portability.
Monthly amount billed to the initial PHA for the family's housing assistance payment (HAP), on-going
administrative fee, and any utility reimbursement to the family.
Enter 0 if the family was absorbed by the receiving PHA.
The initial PHA's 2-letter state code and 3-digit identification number.
Check the housing type that applies to the family's housing unit.
The Section 8 unit owner's legal name.
Tax identification number (TIN) or Social Security Number (SSN) of the legal unit owner.
Total monthly rent amount paid to the unit owner under the lease, or other subsidized rent amount.
If the payment does not include all utilities, the monthly allowance amount for tenant supplied utilities that
apply to the family occupied unit.
To get the unit's total monthly rent amount, or gross rent, add the contract rent to owner (line 11k) and the
utility allowance (line 11m).
The total tenant payment (TTP). Copy from 9j.
Total housing assistance payment (HAP), which is composed of the gross rent of unit (line 11n) minus total
tenant payment (TTP) (line 11q).
The rent amount the family pays to the owner after deducting the total housing assistance payment (HAP) (line
11r) from the contract rent to owner (line 11k), or the total credit amount the family receives to pay utilities.
The amount of the housing assistance payment (HAP) to the unit owner. The lower amount of the contract
rent to owner (line 11k) or total HAP (line 11r).
Indicate the MTW specific alternate rent type the family’s rent is determined by if the family’s rent is not
calculated using the standard rent calculation detailed on this form.
The total housing assistance payment (HAP) to the unit owner for a family if the PHA is utilizing an alternate
rent, as indicated in 11u, or the family is participating in the Local, Non-Traditional Property-Based program.
Tenant rent to owner determined by the PHA for a family if the PHA is utilizing an alternate rent, as indicated
in 11u, or the family is participating in the Local, Non-Traditional Property-Based program.
Amount of the normal total housing assistance payment. Subtract total tenant payment (TTP) (line 11q) from
gross rent (line 11n).
Total number of family members eligible for a rent subsidy based on the Noncitizens Rule.
Total number of family members in household.
Include all family members, including ineligible noncitizen family members (3i= IN). Do not include live-in aides
or foster children/adults.
Percentage of family eligible for rent subsidy. Divide total number eligible (line 11ae) by total number in family
(line 11af).
Total prorated housing assistance payment (HAP). Multiply normal total HAP (line 11aa) by proration
percentage (line 11ag).
Total tenant payment (TTP) for the unit based on the proration calculation. Gross rent of unit (line 11n) minus
prorated total housing assistance payment (HAP) (line 11ah).
Monthly allowance amount for tenant supplied utilities if the payment does not include all utilities. Copy from
line 11m.
The rent amount the family pays to the owner after deducting the utility allowance (line 11aj) from the mixed
family total tenant payment (TTP) (line 11ai), or the total credit amount the family receives to pay utilities.
The total prorated housing assistance payment (HAP) to the unit owner. Subtract the mixed family tenant rent
(line 11ak) from the contract rent to owner (line 11k).
If the mixed family tenant rent (line 11ak) is negative, enter the contract rent to owner (line 11k).
Indicate the MTW specific alternate rent type the family’s rent is determined by if the family’s rent is not
calculated using the standard prorated rent calculation detailed on this form
The total prorated housing assistance payment (HAP) to the unit owner for a family if the PHA is utilizing an
alternate rent, as indicated in 11ap, or the family is participating in the Local, Non-Traditional Property-Based
program.
Prorated tenant rent to owner determined by the PHA for a family if the PHA is utilizing an alternate rent, as
indicated in 11ap, or the family is participating in the Local, Non-Traditional Property-Based program.

ix

form HUD-50058 MTW Expansion (xx/xxxx)

Head of household name

Social Security Number

Date modified (mm/dd/yyyy)

12. Housing Choice Voucher: Tenant-Based Vouchers or Local, Non-Traditional Tenant-Based
12a. Number of bedrooms on Voucher
12b. Is family now moving to this unit? (Y or N)
12c. Does the family qualify as a Hard to House family? (Y or N)
12d. Did family move into your PHA jurisdiction under portability? (Y or N) (if no, skip to 12g)
12e. Cost billed per month (put 0 if absorbed)
12f. PHA code billed
12g. Housing type
[ ] Group Home (prorate gross rent) [ ] Own manufactured home, lease space

$

12a.
12b.
12c.
12d.
12e.
12f.

$

[ ] SRO: 1 room occupied by 1 person

12h. Owner name
12i. Owner TIN/SSN
12j. Payment standard for the family
12k. Rent to owner
12m. Utility allowance, if any
12p. Gross rent of unit: 12k + 12m (or Space Rent)
12q. Lower of 12j or 12p
12r. TTP: copy from 9j
12s. Total HAP: 12q minus 12r

$
$
$
$
$
$
$

12h.
12i.
12j.
12k.
12m.
12p.
12q.
12r.
12s.

Rent Calculation (if prorated rent, skip to 12ab)
12t. Total family share: 12p minus 12s
12u. HAP to owner: lower of 12k or 12s
12v. Tenant rent to owner: 12k minus 12u
12w. Utility reimbursement to family: 12s minus 12u, but do not exceed 12m
[ ] MTW alternative gross income
12x. MTW specific alternate rent type:
[ ] MTW alternative adjusted income

[ ] MTW Stepped rent
[ ] MTW Tiered rent
[ ] Other MTW alternative rent

12y. Alternate HAP to owner (if a selection is made in 12x, including Local, Non-Traditional Tenant-Based
program)
12z. Alternate tenant rent (if a selection is made in 12x, including Local, Non-Traditional Tenant-Based
program)

$

12y.

$

12z.

$

12ab.
12ac.
12ad.
12ae.
12af.
12ag.
12ah.
12ai.
12ai.
12aj.

Prorated Rent Calculation
12ab. Normal total HAP: copy from 12s, but do not exceed 12p
12ac. Total number eligible
12ad. Total number in family
12ae. Proration percentage: 12ac + 12ad
12af. Prorated total HAP: 12ab X 12ae
12ag. Mixed family total family contribution: 12p minus 12af
12ah. Utility allowance: copy from 12m
12ai. Mixed family tenant rent to owner: 12ag minus 12ah

If positive or 0, put tenant rent
If negative, credit tenant
12aj. Prorated HAP to owner: 12k minus 12ai. If 12ai is negative, put 12k
[ ] MTW alternative gross income
[ ] MTW Stepped rent
12ak. MTW specific alternate rent type:
[ ] MTW alternative adjusted income

$
$
$
$
$
$

[ ] MTW Tiered rent

[ ] Other MTW alternative rent

12am. Alternate prorated HAP to owner (if a selection is made in 12ak or for the Local, Non-Traditional
Property-Based program)
12an. Alternate prorated tenant rent (if a selection is made in 12ak, including Local, Non-Traditional
Property-Based program)

$

12am.

$

12an.

$
$

12ap.
12aq.

Additional Payments (not HAP)
12ap. Additional financial support for tenant-based voucher family
12aq. Financial incentive for property owner

10

form HUD-50058 MTW Expansion (xx/xxxx)

12:

Housing Choice Vouchers: Tenant Based Vouchers and Local, Non-Traditional Tenant-Based

Note:

Complete if the family participates in the Tenant-Based Voucher program (1c = T) or Local, Non-Traditional Tenant-Based
(1c = LN) and type of action is New Admission (2a= 1), Annual Reexamination (2a= 2), Interim Reexamination (2a= 3),
Portability Move-in (2a= 4), or Other Change of Unit (2a= 7).

Line 12a:

Unit size (number of bedrooms) listed on the family's Voucher.

Line 12b:

Indicate if the family is now moving into the unit.

Line 12c:

Indicate whether or not the family qualifies as Hard to House. A family qualifies as Hard to House if there are three or
more minors or if there is a disabled family member and the family is moving to a different unit.
Indicate whether or not the household will move or has moved into the PHA's jurisdiction under portability.

Line 12d:
Line 12e:

Monthly amount billed to the initial PHA for the family's housing assistance payment (HAP) amount, on-going
administrative fee, and any utility reimbursement to the family.

Note:

Enter 0 if the family was absorbed by the receiving PHA.

Line 12f:

The initial PHA's 2-letter state code and 3-digit identification number.

Note:

For help obtaining the PHA's identification number, contact the appropriate HUD field office.

Line 12g:

Check the housing type that applies to the family's housing unit.

Line 12h:

The unit owner's legal name.

Line 12i:

Tax identification number (TIN) or Social Security Number (SSN) of the legal unit owner.

Line 12j:

Enter maximum monthly assistance payment for a family assisted in the Voucher program.

Line 12k:

Total monthly rent payable to the unit owner under the lease for the contract unit.

Line 12m:

If the payment does not include all utilities, the monthly allowance amount for tenant supplied utilities that apply to the
family occupied unit.

Line 12p:

Gross rent of unit or space rent. Add rent to owner (line 12k) to the utility allowance (line 12m).

Line 12q:

Lower of Voucher payment standard for family (line 12j) or gross rent of unit (line 12p).

Line 12r:

Total tenant payment (TTP). Copy from 9j.

Line 12s:

Total housing assistance payment (HAP), which is composed of the lower of the payment standard for the family or
gross rent (line 12q) minus total tenant payment (TTP) (line 12r).

Line 12t:

Amount the family contributes toward rent and utilities. Subtract total housing assistance payment (HAP) (line 12s) from
gross rent of unit (line 12p).

Line 12u:

The amount of the housing assistance payment (HAP) to the unit owner. The lower of the rent to owner (line 12k) or total
HAP (line 12s).

Line 12v:

Rent amount the family pays to the owner after deducting the housing assistance payment (HAP) to owner (line 12u) from
the rent to owner (line 12k).

Line 12w:

Line 12ab:

The utility reimbursement to the family from the PHA. Subtract housing assistance payment (HAP) to owner (line 12u)
from total HAP (line 12s), but do not exceed the utility allowance (line 12m).
Indicate the MTW specific alternate rent type the family’s rent is determined by if the family’s rent is not calculated using the
standard rent calculation detailed on this form.
The total housing assistance payment (HAP) to the unit owner for a family if the PHA is utilizing an alternate rent, as indicated
in 12x, or the family is participating in the Local, Non-Traditional Tenant-Based program.
Tenant rent to owner determined by the PHA for a family if the PHA is utilizing an alternate rent, as indicated in 12x, or the
family is participating in the Local, Non-Traditional Tenant-Based program.
The amount of the normal total housing assistance payment (HAP).

Line 12ac:

Total number of family members eligible for rent subsidy based on the Noncitizens Rule.

Line 12x:
Line 12y:
Line 12z:

Line 12ad:

Total number of family members in household.

Note:

Include all family members, including ineligible noncitizen family members (3i= IN). Do not include live-in aides or foster
children/adults.

Line 12ae:

Percentage of family eligible for rent subsidy. Divide total number eligible (line 12ac) by total number in the family
(12ad).
Multiply total normal housing assistance payment (HAP) (line 12ab) by the proration percentage (line 12ae).

Line 12af:
Line 12ag:

The mixed family total family contribution based on the proration calculation. Take the gross rent of unit (line 12p) minus
prorated total housing assistance payment (HAP) (line 12af).

Line 12ah:

If the payment does not include all utilities, the monthly allowance amount for tenant supplied utilities that apply to the
family occupied unit.

Line 12ai:

The rent amount the family pays to the owner after subtracting the utility allowance (line 12ah) from the mixed family total
family contribution (line 12ag); or the total credit amount the family receives to pay for utilities.

Line 12aj:

The total prorated amount of the housing assistance payment (HAP) to the unit owner. Subtract the mixed family tenant
rent to owner (line 12ai) from the rent to owner (line 12k).

Note:

If the mixed family tenant rent to owner (line 12ai) is negative, enter the rent to owner (line 12k).

Line 12ak:

Indicate the MTW specific alternate rent type the family’s rent is determined by if the family’s rent is not calculated using the
standard prorated rent calculation detailed on this form.
The total prorated housing assistance payment (HAP) to the unit owner for a family if the PHA is utilizing an alternate rent, as

Line 12am:

x

form HUD-50058 MTW Expansion (xx/xxxx)

12:

Housing Choice Vouchers: Tenant Based Vouchers and Local, Non-Traditional Tenant-Based
indicated in 12ak, or the family is participating in the Local, Non-Traditional Tenant-Based program.

Line 12an:
Line 12ap:

Prorated tenant rent to owner determined by the PHA for a family if the PHA is utilizing an alternate rent, as indicated in 12ak,
or the family is participating in the Local, Non-Traditional Tenant-Based program.
Total financial assistance provided by the PHA to a household when the household is leasing a new TBV unit.

Line 12aq:

Total financial assistance provided by the PHA to the landlord when a household is leasing a new TBV unit.

xi

form HUD-50058 MTW Expansion (xx/xxxx)

Head of household name

Social Security Number

Date modified (mm/dd/yyyy)

15. Homeownership Vouchers
15a. Is family now moving to this home? (Y or N)
15b. Date (mm/dd/yyyy) of initial HQS inspection
15c. Did family move into your PHA jurisdiction under portability? (Y or N) (if no, skip to15f)
15d. Cost billed per month (put 0 if absorbed)
15e. PHA code billed
15f. Monthly homeownership payment (PITI & MIP if applicable)
15g. Utility allowance
15h. Monthly maintenance allowance
15i. Monthly major repair/replacement allowance
15j. Monthly Co-op/Condominium assessments
15k. Monthly principal and interest on debt for improvements, if any
15m. Gross homeownership expense: 15f + 15g + 15h + 15i + 15j + 15k
15n. Payment standard for family
15p. Lower of 15m and 15n
15q. TTP: copy from 9j
15r. HAP: 15p minus 15q (if 15q is larger, put 0)

$
$
$
$
$
$
$
$
$
$
$

15a.
15b.
15c.
15d.
15e.
15f.
15g.
15h.
15i.
15j.
15k.
15m.
15n.
15p.
15q.
15r.

$

15s.

$

15aa.
15ab.
15ac.
15ad.
15ae.
15af.

$

Subsidy Calculation (if prorated, skip to 15aa)
15s. Total family share: 15m minus 15r
Prorated Subsidy Calculation
15aa. Normal total HAP: copy from 15r
15ab. Total number eligible
15ac. Total number in family
15ad. Proration percentage: 15ab + 15ac
15ae. Prorated HAP: 15aa X 15ad
15af. Mixed family total family share: 15m minus 15ae

$
$

11

form HUD-50058 MTW Expansion (xx/xxxx)

15.

Homeownership Vouchers

Note:

Complete if program type is Homeownership (line 1c = H) and type of action is New Admission (2a= 1),
Annual Reexamination (2a= 2), Interim Reexamination (2a= 3), Portability Move-in (2a= 4), or Other Change
of Unit (2a= 7).
Indicate if the family is now moving into the home.
Date of the initial housing quality standards (HQS) inspection.
Indicate whether or not the household will move or has moved into the PHA's jurisdiction under portability.

Line 15a:
Line 15b:
Line 15c:
Line 15d:
Note:
Line 15e:

Monthly amount billed to the initial PHA for the family's housing assistance payment (HAP) amount, on-going
administrative fee, and any utility reimbursement to the family.
Enter 0 if the family was absorbed by the receiving PHA.
The initial PHA's 2-letter state code and 3-digit identification number.

Note:
Line 15f:

For help obtaining the PHA's identification number, contact the appropriate HUD field office.
The monthly homeownership cost.

Note:

Includes principal and interest on initial mortgage debt, taxes and insurance (PITI) and any mortgage
insurance premium (MIP), if applicable.
The PHA's utility allowance for the unit.
The amount of PHA's allowance for the homeowner's monthly routine maintenance costs.
The amount of the PHA's allowance for the homeowner’s major home repairs and replacements.
If applicable, enter co-op occupancy charges or condominium association assessments.
The amount of principal and interest for debt associated with home improvements on the unit.
Calculation of tenant's total cost of homeownership. Sum of 15f through 15k.

Line 15g:
Line 15h:
Line 15i:
Line 15j:
Line 15k:
Line 15m:
Line 15n:
Line 15p:
Line 15q:
Line 15r:
Note:
Line 15s:
Line 15aa:
Line 15ab:
Line 15ac:
Note:
Line 15ad:
Note:
Line 15ae:
Line 15af:

Enter the lower of the payment standard for the unit size as indicated on the family's Voucher or the payment
standard for the unit size that the family actually owns.
The lower of gross homeownership expense (line 15m) and the payment standard for the family (line 15n).
Total tenant payment (TTP). Copy from 9j.
The amount of monthly homeownership assistance payment (HAP). Subtract total tenant payment (TTP) (line
15q) from the lower of 15m and 15n (line 15p).
If the TTP (line 15q) is larger, enter 0.
Total amount the family contributes toward homeownership. Subtract housing assistance payment (HAP) (line
15r) from gross homeownership expense (line 15m).
The amount of the normal total housing assistance payment.
Total number of family members eligible for homeownership subsidy based on the Noncitizens Rule.
Total number of family members in the household.
Include all family members, including ineligible noncitizen family members (3i= IN). Do not include live-in aides
or foster children/adults.
Percentage of family eligible for homeownership subsidy. Divide the total number eligible (line 15ab) by the
total number in family (line 15ac).
Do not include live-in aides or foster children and adults. Include ineligible noncitizen family members as part
of the total family number.
The total prorated amount of the homeownership assistance payment (HAP) to the homeowner. Multiply
normal total HAP (line 15aa) by the proration percentage (line 15ad).
The mixed family total family contribution based on the proration calculation. Subtract the prorated housing
assistance payment (HAP) (line 15ae) from the gross homeownership expense (line 15m).

xii

form HUD-50058 MTW Expansion (xx/xxxx)

Head of household name

Social Security Number

Date modified (mm/dd/yyyy)

17. Family Self-Sufficiency (FSS)/MTW Self-Sufficiency
17a.
17b.
17c.
17d.
17e.
17f.
17g.
17h.

Participate in special programs? (check all that apply)
[ ] FSS
[ ] MTW self-sufficiency
FSS report category: (check no more than one)
[ ] Enrollment [ ] Progress [ ] Exit
FSS effective date (mm/dd/yyyy) of action
17c.
PHA code of PHA administering FSS contract
17d.
MTW self-sufficiency report category: (check no more than one)
[ ] Enrollment [ ] Progress [ ] Exit
MTW self-sufficiency effective date (mm/dd/yyyy) of action
17f.
PHA code of PHA administering MTW self-sufficiency contract
17g.
General information
(1) Current employment status of head of household. Check the box to indicate the head of household’s employment status
at the time addendum completed.
[ ] Full-time (32 hours per week or more)

[ ] Part-time

[ ] Not employed

(2) Date (mm/dd/yyyy) current employment began
(3) Benefits in current employment: (check all that apply) [ ] Health [ ] Retirement account [ ] Other
(4) Years of school completed by the head of household. Enter the highest grade of education or
years of formal schooling the head of household completed at the time Addendum is submitted.
(0-25)
(5) Assistance received by the family: (check all that apply)
[ ] TANF Income Assistance
[ ] Medicaid/Children’s Health Insurance Program

[ ] General Assistance
[ ] Earned Income Tax Credit

17h(4).

[ ] Food Stamps

(6) Number of children receiving childcare services
17i. FSS family services table (for MTW self-sufficiency go to 17r)
(1)
Need (Y or N)

17h(2).

17h(6).
(2)
Need Met Through
Participation in Program
(Y or N)

(3)
Service Provider

Education/Training
GED
High school
Post secondary
Vocational/Job training
Job search/job placement
Job retention
Transportation
Health services
Alcohol and other drug abuse
prevention services
Mentoring
Homeownership counseling
Individual Development Account
(IDA)
Child care
None
17i (3) Service provider codes:
P = PHA
D = DOL grantee
T = TANF agency
V = Voluntary organization

PR = For profit entity
N = Nonprofit agency

12

E = Employer
C = Community college

form HUD-50058 MTW Expansion (xx/xxxx)

17:
Note:
Line 17a:
Line 17b:
Line 17c:
Line 17d:

Family Self-Sufficiency (FSS)/MTW Self-Sufficiency Addendum
Complete this section if the family participates in the Family Self-Sufficiency or MTW self-sufficiency Programs.
Identify if the family participates in a Family Self-Sufficiency (FSS) program, an MTW self-sufficiency
program, or both.
Check one category to indicate the purpose of the FSS Addendum.
The effective date of the FSS action.
The PHA code associated with the PHA that provides the FSS services.

Note:
Line 17e:
Line 17f:
Line 17g:
Line 17h(1):
Line 17h(2):
Line 17h(3):
Line 17h(4):
Note:

For help obtaining the PHA's identification number, contact the appropriate HUD field office.
Check one category to indicate the purpose of the MTW self-sufficiency Addendum.
The effective date of the MTW self-sufficiency action.
The PHA code associated with the PHA that provides the self-sufficiency services
Indicate the head of household's current employment status.
The date the head of household began his/her current job.
Indicate the head of household's current employment benefits. Check all that apply.
Enter the highest grade or the full years of formal schooling that the head of household completed (0-25).
Years of schooling begin with first grade (do not count kindergarten or pre-school).

Line 17h(5):

Indicate whether or not the family receives additional assistance, such as food stamps, Medicaid, TANF
assistance, or the earned income tax credit.
The number of children in the household who receive childcare services.
Indicate whether or not the PHA identified individual training and service needs of the family members
participating in the FSS program.
If the PHA identified certain needs for family members, indicate whether or not these needs were met during
participation in the FSS program.
Using the codes provided at bottom of page, indicate the type of service provider that meets the participant's
need.
Line 17i is only for the FSS program.

Line 17h(6):
Line 17i(1):
Line 17i(2):
Line 17i(3):
Note:

xiii

form HUD-50058 MTW Expansion (xx/xxxx)

Head of household name

Social Security Number

Date modified (mm/dd/yyyy)

Family Self-Sufficiency Program (if not in FSS program, skip to 17n)
17j. FSS Contract Information
(1) Initial start date (mm/yyyy) of contract of participation (FSS enrollment report only)
(2) Initial end date (mm/yyyy) of contract of participation (FSS enrollment report only)
(3) Contract date extended to (mm/yyyy) (if applicable)
(4) Number of family members with Individual Training and Services Plan
(5) Did the family receive selection preference because of a FSS related service program
participation? (FSS enrollment report only) (Y or N)
17k. FSS account information
(1) Current FSS account monthly credit
(2) Current FSS account balance
(3) FSS account amount disbursed to the family (cumulative as of end of reporting period)
17m. FSS exit information (FSS Exit Report only)
(1) Did family complete contract of participation? (Y or N)
(2) If (1) is Yes, did family move to homeownership? (Y or N)
(3) If (1) is No, primary reason for exit:
[ ] Left voluntarily
[ ] Asked to leave program

17j(1).
17j(2).
17j(3).
17j(4).
17j(5).

$

17k(1).
17k(2).
17k(3).

[ ] Portability move-out
[ ] Contract expired but family did not fulfill obligations
[ ] Left because essential service was unavailable

MTW Self-Sufficiency Program
17n. MTW self-sufficiency Contract Information
(1) Initial start date (mm/yyyy) of contract of participation (Enrollment report only)
(2) Initial end date (mm/yyyy) of contract of participation (Enrollment report only)
(3) Contract date extended to (mm/yyyy) (if applicable)
(4) Number of family members with Individual Training and Services Plan
(5) Did the family receive selection preference because of a related service program participation?
(Enrollment report only) (Y or N)
17p. MTW self-sufficiency Escrow account information
(1) Current account monthly credit
(2) Current account balance
(3) Account amount disbursed to the family (cumulative as of end of reporting period)
17q. MTW self-sufficiency exit information (MTW self-sufficiency Exit Report only)
(1) Did family complete contract of participation? (Y or N)
(2) If (1) is Yes, did family move to homeownership? (Y or N)
(3) If (1) is No, primary reason for exit:
[ ] Left voluntarily
[ ] Asked to leave program

17n(1).
17n(2).
17n(3).
17n(4).
17n(5).

$
$
$

17p(1).
17p(2).
17p(3).
17q(1).
17q(2).

[ ] Portability move-out
[ ] Contract expired but family did not fulfill obligations
[ ] Left because essential service was unavailable

17r. MTW self-sufficiency family services table (for FSS go to 17i)
(1)
Need (Y or N)

(2)
Need Met Through
Participation in Program
(Y or N)

(3)
Service Provider

Education/Training
GED
High school
Post secondary
Vocational/Job training
Job search/job placement
Job retention
Transportation
Health services
Alcohol and other drug abuse
prevention services
Mentoring
Homeownership counseling
Individual Development Account
(IDA)
Child care
None
17r (3) Service provider codes:
P = PHA
D = DOL grantee
T = TANF agency
V = Voluntary organization

PR = For profit entity
N = Nonprofit agency

13

E = Employer
C = Community college

form HUD-50058 MTW Expansion (xx/xxxx)

17:

Family Self-Sufficiency (FSS)/MTW Self-Sufficiency Addendum (continued)

Line 17j(1):

FSS enrollment report only. The effective date of the family's FSS contract of participation; the date the family
initially enrolled in the FSS program.
FSS enrollment report only. The expiration date of the family's FSS contract of participation; the date the
family is initially expected to exit the FSS program. The contract term is for a period of 5 years.
If applicable, the date to which the PHA has extended the family's FSS contract of participation.

Line 17j(2):
Line 17j(3):
Line 17j(4):
Line 17j(5):
Line 17k(1):
Line 17k(2):
Line 17k(3):
Line 17m(1):

Line 17m(2):
Line 17m(3):

The number of family members in the household who have current Individual Training and Services Plans
under the FSS contract of participation.
For new FSS enrollment, indicate whether or not the family received an FSS selection preference due to
participation in a related service program.
The current dollar amount credited to the family's FSS account due to increases in earned income by the
family.
The current dollar amount of the family's FSS account based on the most recent report of account funds and
activity.
Total dollar cumulative amount, if any, of all FSS escrow disbursements ever made to the family.
Indicate if the family fulfilled all of its obligations under the contract during the contract term, or when 30% of
the family's monthly adjusted income equals or exceeds the existing housing fair market rent (FMR) for the
unit size for which the family qualifies.
Indicate if the family completed the contract and is moving to homeownership.
Indicate why the family is not moving to homeownership (why family exited the program).

Line 17n(1):

MTW self-sufficiency enrollment report only. The effective date of the family's FSS contract of participation; the
date the family initially enrolled in the self-sufficiency program.

Line 17n(2):

MTW self-sufficiency enrollment report only. The expiration date of the family's FSS contract of
participation; the date the family is initially expected to exit the self-sufficiency program.
If applicable, the date to which the PHA has extended the family's MTW self-sufficiency contract of
participation.
The number of family members in the household who have current Individual Training and Services Plans
under the contract of participation.
For new MTW self-sufficiency enrollment, indicate whether or not the family received a selection
preference due to participation in a related service program.
The current dollar amount credited to the family’s account due to increases in earned income by the
family.
The current dollar amount of the family’s account based on the most recent report of account funds and
activity.
Total dollar cumulative amount, if any, of all escrow disbursements ever made to the family.
Indicate if the family fulfilled all of its obligations under the contract during the contract term.
Indicate if the family completed the contract and is moving to homeownership.
Indicate why the family did not complete its MTW self-sufficiency contract.
Indicate whether or not the PHA identified individual training and service needs of the family members.
If the PHA identified certain needs for family members, indicate whether or not the program meets these
needs.
Using the codes provided at bottom of page, indicate the type of service provider that meets the participant’s
need.
Line 17r is only for the MTW self-sufficiency program.

Line 17n(3):
Line 17n(4):
Line 17n(5):
Line 17p(1):
Line 17p(2):
Line 17p(3):
Line 17q(1):
Line 17q(2):
Line 17q(3):
Line 17r(1):
Line 17r(2):
Line 17r(3):
Note:

xiv

form HUD-50058 MTW Expansion (xx/xxxx)