HOTMA Report

OMB Approval Number 2577-0083 (expires xx/xx/20xx)

U.S. Department of Housing and

Urban Development

Office of Public and Indian Housing

MTW Family Report

Form HUD­50058 MTW, Family Report, applies to Moving to Work Public Housing, Section 8 and Local, Non-Traditional programs.

Additional instructions are contained in the Form HUD­50058 MTW Instruction Booklet.

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), the Fair Housing Act (42 U.S.C. 3601­19), and by the Omnibus Consolidated Rescissions and Appropriations Act of 1996 (42 U.S.C.1437f). 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. HUD will use the information to: (1) monitor program participants’ compliance with requirements, (2) provide demographic information describing tenants’ characteristics, (3) participate in income matching, to detect fraud, and (4) plan for future use of the housing inventory with emphasis on the housing needs of special groups. 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

FSS = Family Self-Sufficiency program HAP = Housing Assistance Payment HQS = Housing Quality Standards HUD = U.S. Department of Housing & Urban Development INS = U.S. Immigration and Naturalization Services OMB = U. S. Office of Management and Budget PHA = Public Housing Agency

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 MTW = Moving to Work

Major Definitions (refer to the Form HUD-50058 MTW Instruction Booklet for a more detailed definition of each field on the Form):

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 Section 8 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.

MTW Family Report U.S. Department of Housing and Urban Development OMB Approval Number 2577-0083 Office of Public and Indian Housing Expires xx/xx/20xx
1. MTW Agency
1a. Agency name		1a.
1b. PHA code		1b.
1c. Program	P = Public Housing T = TenantBased Assistance PR = ProjectBased Assistance H = Traditional Homeownership LH = Local, NonTraditional Homeownership LN = Local, NonTraditional Assistance	1c.
1d. Project Number (Public Housing only)		1d.
1e. Building Number (Public Housing only)		1e.
1f. Building Entrance Number (Public Housing only)		1f.
1g. Unit Number (Public Housing only)		1g.
2. MTW Action
2a. Type of Action		2a.
2b. Effective date (mm/dd/yyyy) of action		2b.
2c. Correction? (Y or N)		2c.
2d. If correction: (check primary reason) [ ] Family correction of income [ ] Family correction (non-income) [ ] PHA correction of family income [ ] PHA correction (non-income)
2e. Date correction transmitted (mm/dd/yyyy)		2e.
2f. Repayment agreement (Y or N)		2f.
2g. Monthly amount of repayment		2g.
2h. Date (mm/dd/yyyy) of admission to program		2h.
2i. Projected effective date (mm/dd/yyyy) of next reexamination		2i.
2j. Date (mm/dd/yyyy) of admission to Moving to Work program		2j.
2k. FSS participation now or in last year? (Y or N)		2k.
2m. MTW selfsufficiency program participation now or in last year? (Y or N)		2m.
2n. Reserved		2n.
2p. Use if instructed by HUD		2p.
2q. PHA use only		2q.
2r. PHA use only		2r.
2s. PHA use only		2s.
2t. PHA use only		2t.
2u. PHA use only		2u.
2a. Type of action codes 1 = New Admission 2 = Annual Reexamination 3 = Interim Reexamination 4 = Portability Move-in (Voucher only) 5 = Portability Move-out (Voucher only) 6 = End Participation 7 = Other Change of Unit 8 = FSS/MTW Self-Sufficiency Addendum Only 9 = Annual Reexamination Searching (Voucher only) 10 = Issuance of Voucher (Voucher only) 11 = Expiration of Voucher (Voucher only) 12 = Reserved 13 = Annual HQS Inspection Only (Voucher only) 14 = Historical Adjustment 15 = Void 16 = Household Composition Change Only

	Page Heading
Head of household name:	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.
Social Security Number	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.
Date modified (mm/dd/yyyy)	On every page, enter the date the PHA representative fills out the Form or modifies any Form page.
1:	MTW Agency
Line 1a:	Name of the Public Housing Agency (PHA) that completes the family’s Form HUD­50058 MTW.
Line 1b:	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.
Line 1c:	Using the codes provided, indicate the housing assistance program in which the family participates.
Line 1d:	Public Housing only. The project number is composed of the 2-letter project state code, 3-digit PHA number, and 6-digit project number.
Line 1e:	Public Housing only. Six-character code to capture the tenant’s building number.
Line 1f:	Public Housing only. Three-character code to capture the building’s entrance number.
Line 1g:	Public Housing only. Ten-character code to capture the PHA designated tenant unit number.
2:	MTW Action
Line 2a:	Use the codes provided to report the family’s type of action.
Line 2b: Note:	Date the reported action becomes effective. The effective date cannot be earlier than the date of admission to the program (line 2h).
Line 2c: Note:	Allows PHAs to correct fields previously transmitted in error. Use a correction for a minor change to a previously submitted record.
Line 2d:	Indicate the primary reason for the correction record.
Line 2e:	The actual date that the PHA completes the correction and transmits the corrected record.
Line 2f:	Indicate if the tenant has entered into a repayment agreement because the tenant previously underreported or misreported income.
Line 2g:	Per the repayment agreement, the amount the tenant pays each month.
Line 2h:	Date the PHA initially admitted the family into the regular (non-MTW) version of the program reported in line 1c.
Line 2i:	The projected effective date of the family’s next reexamination.
Line 2j:	Date the PHA admitted the family to the Moving to Work program.
Line 2k:	Indicate if the family currently participates or participated in the Family Self-Sufficiency program in the past year.
Line 2m:	Indicate if the family currently participants or participated in an MTW self-sufficiency program in the past year.
Line 2n:	Reserved.
Line 2p:	HUD may instruct a particular PHA to use this line. If there are not instructions to use these lines, leave them blank.
Line 2q­2u: Note:	PHAs may use these lines for any information they wish to collect. HUD encourages PHAs to use lines 2q through 2u for local initiatives.

3. MTW Household

3a. Head of Household Member number 01	3b. Last name & Sr., Jr. etc.				3c. First name	3d. MI		3e. Date of birth	3f. Age on effective date of action
	3g. Sex	3h. Relation H		3i. Citizenship	3j. Disability (Y or N)	3k. Race [ ] 1. [ ] 2. [ ] 3. [ ] 4. [ ] 5.			3m. Ethnicity
	3n. Social Security Number				3p. Alien Registration Number A-			3q. Meeting community service or self- sufficiency requirement? (PH only)
	3r. Total years of school (0-25)
3a. Member number 02	3b. Last name & Sr., Jr. etc.				3c. First name	3d. MI		3e. Date of birth	3f. Age on effective date of action
	3g. Sex	3h. Relation		3i. Citizenship	3j. Disability (Y or N)	3k. Race [ ] 1. [ ] 2. [ ] 3. [ ] 4. [ ] 5.			3m. Ethnicity
	3n. Social Security Number				3p. Alien Registration Number A-			3q. Meeting community service or self- sufficiency requirement? (PH only)
	3r. Total years of school (0-25)
3a. Member number 03	3b. Last name & Sr., Jr. etc.				3c. First name	3d. MI		3e. Date of birth	3f. Age on effective date of action
	3g. Sex	3h. Relation		3i. Citizenship	3j. Disability (Y or N)	3k. Race [ ] 1. [ ] 2. [ ] 3. [ ] 4. [ ] 5.			3m. Ethnicity
	3n. Social Security Number				3p. Alien Registration Number A-			3q. Meeting community service or self- sufficiency requirement? (PH only)
	3r. Total years of school (0-25)
3a. Member number 04	3b. Last name & Sr., Jr. etc.				3c. First name	3d. MI		3e. Date of birth	3f. Age on effective date of action
	3g. Sex	3h. Relation		3i. Citizenship	3j. Disability (Y or N)	3k. Race [ ] 1. [ ] 2. [ ] 3. [ ] 4. [ ] 5.			3m. Ethnicity
	3n. Social Security Number				3p. Alien Registration Number A-			3q. Meeting community service or self- sufficiency requirement? (PH only)
	3r. Total years of school (0-25)
3a. Member number 05	3b. Last name & Sr., Jr. etc.				3c. First name	3d. MI		3e. Date of birth	3f. Age on effective date of action
	3g. Sex	3h. Relation		3i. Citizenship	3j. Disability (Y or N)	3k. Race [ ] 1. [ ] 2. [ ] 3. [ ] 4. [ ] 5.			3m. Ethnicity
	3n. Social Security Number				3p. Alien Registration Number A-			3q. Meeting community service or self- sufficiency requirement? (PH only)
	3r. Total years of school (0-25)
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 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 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.	MTW Household
Note:	Complete for each household member.
Note:	The first family member (member number 01) must be the head of household.
Note:	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.
Line 3a:	The member number identifies the individual listed on that line of the Form.
Line 3b:	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.
Line 3c:	The first name of each household member. Do not include name prefixes, such as Ms. or Mr.
Line 3d:	The middle initial of each household member. If no middle initial, leave blank. If more than one middle initial, only enter one.
Line 3e:	The date of birth for each household member.
Line 3f:	The age in years of each household member on the effective date of action (line 2b).
Line 3g:	Indicate the gender of each household member.
Line 3h:	Select the code at bottom of the page that best categorizes the relation or role of each household member.
Line 3i:	Select the code at the bottom of page that indicates each household member's United States citizenship status.
Line 3j:	Indicate whether or not the household member has a disability.
Line 3k:	Use code or codes at bottom of page that the family says best indicates each household member’s race. Select as many codes as appropriate.
Line 3m:	Use code at bottom of page and check the box next to the code the family says best indicates each household member’s ethnicity.
Line 3n:	Enter the 9-digit Social Security Number (SSN) issued to each household member by the Social Security Administration (SSA).
Line 3p:	Enter the Alien Registration Number or A-number issued to each noncitizen household member, if applicable.
Note:	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 is nine digits, enter the number without a leading zero. Do not enter the letter A in any case.
Line 3q:	Public Housing only. Use code at bottom of page to indicate whether the family member met his or her community service requirements under PHRA.
Note:	The law requires an average of eight hours of community service per month during the year.
Line 3s:	Indicate whether additional household member information is included on an additional sheet of paper as an attachment to the Form.

3a. Member number	3b. Last name & Sr., Jr. etc.				3c. First name	3d. MI		3e. Date of birth		3f. Age on effective date of action
	3g. Sex	3h. Relation H		3i. Citizenship	3j. Disability (Y or N)	3k. Race [ ] 1. [ ] 2. [ ] 3. [ ] 4. [ ] 5.				3m. Ethnicity
	3n. Social Security Number				3p. Alien Registration Number A-			3q. Meeting community service or self- sufficiency requirement? (PH only)
	3r. Total years of school (0-25)
3a. Member number	3b. Last name & Sr., Jr. etc.				3c. First name	3d. MI		3e. Date of birth		3f. Age on effective date of action
	3g. Sex	3h. Relation		3i. Citizenship	3j. Disability (Y or N)	3k. Race [ ] 1. [ ] 2. [ ] 3. [ ] 4. [ ] 5.				3m. Ethnicity
	3n. Social Security Number				3p. Alien Registration Number A-			3q. Meeting community service or self- sufficiency requirement? (PH only)
	3r. Total years of school (0-25)
3a. Member number	3b. Last name & Sr., Jr. etc.				3c. First name	3d. MI		3e. Date of birth		3f. Age on effective date of action
	3g. Sex	3h. Relation		3i. Citizenship	3j. Disability (Y or N)	3k. Race [ ] 1. [ ] 2. [ ] 3. [ ] 4. [ ] 5.				3m. Ethnicity
	3n. Social Security Number				3p. Alien Registration Number A-			3q. Meeting community service or self- sufficiency requirement? (PH only)
	3r. Total years of school (0-25)
3a. Member number	3b. Last name & Sr., Jr. etc.				3c. First name	3d. MI		3e. Date of birth		3f. Age on effective date of action
	3g. Sex	3h. Relation		3i. Citizenship	3j. Disability (Y or N)	3k. Race [ ] 1. [ ] 2. [ ] 3. [ ] 4. [ ] 5.				3m. Ethnicity
	3n. Social Security Number				3p. Alien Registration Number A-			3q. Meeting community service or self- sufficiency requirement? (PH only)
	3r. Total years of school (0-25)
3a. Member number	3b. Last name & Sr., Jr. etc.				3c. First name	3d. MI		3e. Date of birth		3f. Age on effective date of action
	3g. Sex	3h. Relation		3i. Citizenship	3j. Disability (Y or N)	3k. Race [ ] 1. [ ] 2. [ ] 3. [ ] 4. [ ] 5.				3m. Ethnicity
	3n. Social Security Number				3p. Alien Registration Number A-			3q. Meeting community service or self- sufficiency requirement? (PH only)
	3r. Total years of school (0-25)
3s. Continued on an additional sheet? (Y or N)									3s.
3t. Total number in household									3t.
3u. Family subsidy status under Noncitizens Rule									3u.
3v. Eligibility effective date (mm/dd/yyyy) if qualified for continuation of full assistance (3u=C)									3v.
3w. If new head of household, former head of household’s SSN									3w.
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 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 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.	MTW Household
Note:	Complete for each household member.
Note:	The first family member (member number 01) must be the head of household.
Note:	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.
Line 3a:	The member number identifies the individual listed on that line of the Form.
Line 3b:	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.
Line 3c:	The first name of each household member. Do not include name prefixes, such as Ms. or Mr.
Line 3d:	The middle initial of each household member. If no middle initial, leave blank. If more than one middle initial, only enter one.
Line 3e:	The date of birth for each household member.
Line 3f:	The age in years of each household member on the effective date of action (line 2b).
Line 3g:	Indicate the gender of each household member.
Line 3h:	Select the code at bottom of the page that best categorizes the relation or role of each household member.
Line 3i:	Select the code at the bottom of page that indicates each household member's United States citizenship status.
Line 3j:	Indicate whether or not the household member has a disability.
Line 3k:	Use code or codes at bottom of page that the family says best indicates each household member’s race. Select as many codes as appropriate.
Line 3m:	Use code at bottom of page and check the box next to the code the family says best indicates each household member’s ethnicity.
Line 3n:	Enter the 9-digit Social Security Number (SSN) issued to each household member by the Social Security Administration (SSA).
Line 3p:	Enter the Alien Registration Number or A-number issued to each noncitizen household member, if applicable.
Note:	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 is nine digits, enter the number without a leading zero. Do not enter the letter A in any case.
Line 3q:	Public Housing only. Use code at bottom of page to indicate whether the family member met his or her community service requirements under PHRA.
Note:	The law requires an average of eight hours of community service per month during the year.
Line 3s:	Indicate whether additional household member information is included on an additional sheet of paper as an attachment to the Form.
Line 3t:	The total number of people in the household.
Note:	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.
Line 3u:	Code 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.
Note:	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.
Line 3v:	Date the family originally qualified for the continuation of full assistance (3u= C).
Line 3w:	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).

4. MTW Family Background at Admission

4a. Date (mm/dd/yyyy) entered waiting list				4a.
4b. ZIP code before admission				4b.
4c. Homeless at admission? (Y or N)				4c.
4d. Reserved				4d.
4e. Continuously assisted under the 1937 Housing Act? (Y or N)				4e.
4f. Reserved				4f.
5. MTW 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)				5b.
5c. Family’s mailing address
Number and street			Apt.
City	State	ZIP code (+4)
5d. Number of bedrooms in unit				5d.
5e. Has the PHA identified this unit as an accessible unit? (Public Housing only) (Y or N)				5e.
5f. Has the family requested accessibility features? (Public Housing only) (Y or N) (if no, skip to next section)				5f.
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 (Tenant-Based or Project-Based Assistance only, except Homeownership)				5h.
5i. Date (mm/dd/yyyy) of last annual HQS inspection (Tenant-Based or Project-Based Assistance only except Homeownership)				5i.
5j. Year (yyyy) unit was built (Tenant-Based or Project-Based Assistance only)				5j.
5k. Structure type (check only one) (Tenant-Based or Project-Based Assistance only) [ ] Single family detached [ ] Semi-detached [ ] Rowhouse/townhouse [ ] Low-rise [ ] High rise with elevator [ ] Manufactured home

Note: The numbering for the following sections skips to Section 18. Form HUD-50058 MTW does not contain any sections labeled Section 6 through Section 17. Sections with these numbers were excluded to ensure that data elements on the regular Form HUD-50058 and Form HUD-50058 MTW have unique numerical labels.

4:	MTW 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.
Note:	This date must not be later than effective date of action (line 2b).
Line 4b:	The 5-digit ZIP code (+ 4, if applicable) where the family lived before admission to an assistance program.
Line 4c:	Indicate whether or not the family was homeless at the time the PHA admitted the family to a housing assistance program.
Line 4d:	Reserved.
Line 4e:	Indicate whether or not the family is continuously assisted under or currently enrolled in any 1937 Housing Act program at the time of admission.
Line 4f:	Reserved.
5:	MTW Unit to be Occupied on Effective Date of Action
Line 5a:	The complete address of the housing unit that the household occupies on the effective date of action (line 2b).
Line 5b:	Indicate whether the mailing address is different from the unit address.
Line 5c:	The complete address where the family receives mail, if other than the unit address provided in line 5a.
Note:	Leave this field blank if the mailing address is the same as the unit address.
Line 5d:	Total number of bedrooms in the unit that the household will occupy on the effective date of action (line 2b).
Line 5e:	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.
Line 5f:	Public Housing only. Indicate whether or not the family requested disability amenities or accessibility features.
Line 5g:	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).
Line 5h:	Tenant-Based or Project-Based Assistance only, except Homeownership. The last date the unit passed a full housing quality standards (HQS) inspection.
Line 5i:	Tenant-Based or Project-Based Assistance only, except Homeownership. The last date a PHA inspector performed a full annual housing quality standards (HQS) inspection of the unit that the household occupies.
Note:	This date may be different from the date unit last passed HQS inspection (line 5h) if the unit failed the last HQS inspection.
Line 5j:	Tenant-Based or Project-Based Assistance only. The year that the unit was built.
Note:	This date is found on the request for tenancy approval form.
Line 5k:	Section 8 only. The building structure type.
Note:	See the Instruction Booklet for descriptions of each housing type.
Note:	The numbering for the following sections skips to Section 18. Form HUD-50058 MTW does not contain any sections labeled Section 6 through Section 17. Sections with these numbers were excluded to ensure that data elements on the regular Form HUD-50058 and Form HUD-50058 MTW have unique numerical labels.

18. MTW Asset Income

18a. Family Member Name	No.	18b. Type of asset	18c. Calculation (PHA use)	18d. Cash value of asset	18e. Anticipated Income	18f. Imputed Income
				$	$	$
				$	$	$
				$	$	$
				$	$	$
				$	$	$
				$	$	$
				$	$	$
				$	$	$
18g Column totals18h, 18i.,				$ g.18	$ 18h.	$ 18i.
18. Passbook rate (written as decimal)j						$ 18j.
18. Final asset income: k18h for directions)ii (see page v18 +						$ 18k.

19. MTW Income

19a. Family Member Name	No.	19b. Income Code		19c. Calculation (PHA use)	19d. Dollars per year		19e. Income exclusions	19f. Income after exclusions (19d minus 19e)
					$		$	$
					$		$	$
					$		$	$
					$		$	$
					$		$	$
					$		$	$
					$		$	$
					$		$	$
					$		$	$
					$		$	$
					$		$	$
					$		$	$
19g., 19h. Column totals					$ 19g.			$ 19h.
19i. Total annual income: 18j + 19h								$ 19i.
19j. Deductions								$ 19j.
19k. Adjusted annual income: 19i + 19j								$ 19k.
7b. Income Codes Wages: B = own business F = federal wage HA = PHA wage M = military pay W = other wage			Welfare: G = general assistance IW = annual imputed welfare income T = TANF assistance SS/SSI/Pensions: P = pension S = SSI SS = Social Security			Other Income Sources C = child support E = medical reimbursement I = Indian trust/per capita N = other nonwage sources U = unemployment benefits X = MTW income

6:	MTW Assets
Note:	Use a separate line for each family member and asset type.
Line 18a:	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.
Line 18b:	List any asset that has a dollar value or provides a source of income to the person
Note:	See the Form HUD-50058 Instruction Booklet for an explanation of allowable assets.
Line 18c:	Use this column to perform asset calculations.
Line 18d:	Estimated, known or calculated dollar value of the asset listed.
Line 18e:	Total amount of income the family member expects to receive in the next 12-month period from the asset listed, or the actual asset income received if using prior-year income.
Line 18f:	The imputed income the family member would receive in the 12-month period from the asset listed. Imputed income is calculated by multiplying the cash value of the asset by the current passbook savings rate. Imputed income should only be calculated if the actual/anticipated income for that source cannot be determined and the total cash value of all assets for the family is above the current net family assets threshold. This threshold changes annually to reflect inflation. In 2023, the net family assets threshold was $50,000. See the [name of HUD webpage with current information] for the current net family assets threshold. See the Instruction Booklet for further details.
Line 18g:	Total of the values listed in column 18d.
Line 18h:	Total of the values listed in column 18e.
Line 18i:	Total of the values listed in column 18f.
Line 18j:	Enter the passbook rate as a decimal.
Line 18k:	Total amount of household income derived from assets.
19:	MTW Income
Note:	If the family members do not have any income from sources other than assets and do not expect any other income in the next 12month period, leave 19a through 19h blank. Fill in total annual income (line 19i), which would be the total of the asset income.
Line 19a:	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.
Line 19b:	Use one or two letter code at bottom of page that represents the type of income for a family member.
Note:	See the Form HUD-50058 MTW Instruction Booklet for a detailed description of each income code.
Line 19c:	Use this column to perform income calculations.
Line 19d:	Annual income amount the family member earns from the income source(s) listed.
Note:	See the Form HUD-50058 MTW Instruction Booklet for a description of each income source.
Line 19e:	Income excluded from annual income calculations.
Note:	Includes income disallowance and individual savings accounts (ISA) for Public Housing.
Note:	See the Form HUD-50058 MTW Instruction Booklet for a description of each income exclusion.
Line 19f:	Income minus exclusions. Take dollars per year (line 19d) minus income exclusions (line 19e).
Line 19g:	The total dollar amounts listed in column 19d.
Line 19h:	The total dollar amounts listed in column 19f.
Line 19i:	The family’s total annual income. Add the final asset income (line 18j) and the total income after income exclusions (line 19h).
Line 19j:	Total amount of money that is deducted from a family’s income for rent determination purposes.
Line 19k:	The family’s adjusted annual income. Take total annual income (line 19i) minus deductions (line 19j).

20. MTW Public Housing

20a. Type of rent selected: [ ] Income-based [ ] Flat	20a.
20b. Tenant rent	$ 20b.
20c. Mixed family tenant rent	$ 20c.
20d. Utility allowance/estimate	$ 20d.
20e. Is this a ceiling rent? (Y or N)	20e.
20f. Reserved	20f.
20g. What is the applicable over-income limit for families of this size?	$ .20g
20h Y [ ] N[ ] Is the family over-income? .	20h.
20i. Date over-income family began the 24 consecutive month grace period	20i.

21. MTW Tenant-Based or Project-Based Assistance or Local, Non-Traditional Assistance

	21a. Indicate if flat subsidy or income-based subsidy:	[ ] Income-based [ ] Flat
21b. Number of bedrooms on voucher equivalent			21b.
21c. Is family now moving to this unit? (Y or N)			21c.
21d. Did family move into your PHA jurisdiction under portability? (Y or N) (if no, skip to 21g)			21d.
21e. Cost billed per month (put 0 if absorbed)			$ 21e.
21f. PHA code billed			21f.
21g. Owner name			21g.
21h. Owner TIN/SSN			21h.
21i. Rent to owner			21i.
21j. Utility allowance/estimate			$ 21j.
21k. Gross rent of unit: 21i + 21j (or Space Rent)			$ 21k.
21m. Flat subsidy amount, if any			$ 21m.
21n. Tenant rent to owner			$ 21n.
21p. Mixed family tenant rent to owner			$ 21p.
21q. Is this a ceiling rent? (Y or N)			21q.
21r. Reserved			21r.

20:	MTW Public Housing
Note:	Complete if the family’s program type is MTW Public Housing (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).
Line 20a:	Indicate whether the family pays an income-based rent or a flat rent.
Note:	Flat rent is not set by the family’s income.
Line 20b:	The rent amount the family pays to the owner.
Line 20c:	The rent amount the mixed family pays to the owner.
Line 20d:	If the payment does not include all utilities, indicate the monthly allowance amount for tenant supplied utilities that applies to the family occupied unit or an estimate of the utility costs.
Note:	If the tenant rent includes all utilities, enter 0.
Line 20e:	Indicate if the family is paying the ceiling rent for this unit.
Line 20f:	Reserved.
Line 20g:	The over-income limit is set by multiplying the applicable area’s very low-income level for the family size by a factor of 2.4.
Line 20h:	Indicate if the family’s adjusted annual income exceeds the over-income limit.
Line 20i:	Line 20i should only be completed if “Y” is selected in 20h. Indicate when the family first began the two-year grace period outlined in the Housing Opportunity Through Modernization Act of 2016 (HOTMA) and related guidance. Note that if the family falls below the over-income limit at any time during the 24 consecutive month grace period and subsequently exceeds it again, the grace period starts over.
21:	MTW Tenant-Based or Project-Based Assistance
Note:	Complete if the family’s program type is (1c=PR) for Project-Based Assistance or (1c=T) for Tenant-Based Assistance 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 21a:	Indicate whether the family pays an income-based subsidy or a flat subsidy.
Note:	Flat subsidies are not set by the family’s income.
Line 21b:	Unit size (number of bedrooms) listed on the family’s voucher equivalent
Line 21c:	Indicate if the family is now moving into the unit.
Line 21d:	Indicate whether or not the household will move or has moved into the PHA’s jurisdiction under portability.
Line 21e:	Monthly amount billed to the initial PHA for the family’s housing assistance payment (HAP), ongoing Administrative fee, and any utility reimbursement to the family.
Note:	Enter 0 if the family was absorbed by the receiving PHA.
Line 21f:	The initial PHA’s 2-letter state code and 3-digit identification number.
Line 21g:	The unit owner’s legal name.
Line 21h:	Tax identification number (TIN) or Social Security Number (SSN) of the legal unit owner.
Line 21i:	Total monthly rent payable to the unit owner under the lease for the contract unit.
Line 21j:	If the payment does not include all utilities, indicate the monthly allowance amount for tenant supplied utilities that apply to the family occupied unit or an estimate of utility costs.
Note:	If the payment includes all utilities, enter 0.
Line 21k:	Gross rent of unit or space rent. Add rent to owner (line 21i) to the utility allowance (line 21j).
Line 21m:	Amount of monthly flat subsidy that the PHA provides to unit owner, if any (line 21a=F).
Line 21n:	Rent amount the family pays to the owner.
Line 21p:	Rent amount the mixed family pays to the owner
Line 21q:	Indicate if the family is paying the ceiling rent for this unit.
Line 21r:	Reserved.

d

22. MTW Homeownership or MTW Local, Non-Traditional Homeownership

	22a. Indicate if flat subsidy or income-based subsidy:	[ ] Income-based [ ] Flat
22b. Is family now moving to this home? (Y or N)			22b.
22c. Date (mm/dd/yyyy) of initial HQS inspection			22c.
22d. Did family move into your PHA jurisdiction under portability? (Y or N) (if no, skip to 22g)			22d.
22e. Cost billed per month (put 0 if absorbed)			$ 22e.
22f. PHA code billed			22f.
22g. Monthly homeownership payment (PITI & MIP if applicable)			$ 22g.
22h. Utility allowance/estimate			$ 22h.
22i. Other monthly allowance(s), if any			$ 22i.
22j. Gross homeownership expense			$ 22j.
22k. Flat subsidy amount			$ 22k.
22m. Total family share			$ 22m.
22n. Mixed family total family share			$ 22n.
22p. Is this a ceiling rent? (Y or N)			22p.
22q. Reserved			22q.

22:	MTW Homeownership
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).
Line 22a:	Indicate if flat subsidy or income-based subsidy.
Note:	Flat subsidies are not set by the family’s income.
Line 22b:	Indicate if the family is now moving into the home.
Line 22c:	Date of the initial housing quality standards (HQS) inspection.
Line 22d:	Indicate whether or not the household will move or has moved into the PHA’s jurisdiction under portability.
Line 22e:	Monthly amount billed to the initial PHA for the family’s housing assistance payment (HAP) amount, ongoing administrative fee, and any utility reimbursement to the family.
Note:	Enter 0 if the family was absorbed by the receiving PHA.
Line 22f:	The initial PHA’s 2-letter state code and 3-digit identification number.
Line 22g:	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.
Line 22h:	The PHA’s utility allowance for the unit.
Note:	If the PHA does not provide a utility allowance, enter an estimate of utility costs.
Line 22i:	The amount of PHA’s allowances for the homeowner’s monthly routine maintenance costs, major home repairs and maintenance, and co-op/condominium assessments.
Line 22j:	Calculation of tenant’s total cost of homeownership. Sum of 22g through 22i.
Line 22k:	Total monthly amount of subsidy the PHA contributes toward homeowners if a flat subsidy is provided to the family.
Line 22m:	Total amount the family contributes toward homeownership.
Lien 22n:	Indicate the mixed family total family contribution based on the proration calculation.
Line 22p:	Indicate if the family is paying the ceiling payment for this unit.
Line 22q:	Reserved.

23. Family Self Sufficiency (FSS)/MTW Self Sufficiency Addendum

23a. Participate in special programs? (check no more than one)) [ ] FSS [ ] MTW self-sufficiency
23b. Report category (check no more than one) [ ] Enrollment [ ] Progress [ ] Exit
23c. Effective date (mm/dd/yyyy) of self-sufficiency action						23c.
23d. PHA code of PHA administering contract						23d.
23e: Reserved						23e.
23f: Reserved						23f.
23g: Reserved						23g.
23h. General information
Current employment status of head of household. Check the box to indicate the head of househo ld’s employment status at the time Addendum completed. [ ] Full-time (32 hours per week or more) [ ] Part-time [ ] Not employed
Date (mm/dd/yyyy) current employment began						23h(2).
Benefits in current employment: (check all that apply) [ ] Health [ ] Retirement account [ ] Other
Reserved.						23h(4).
Assistance received by the family: (check all that apply) [ ] TANF Income Assistance [ ] General Assistance [ ] Food Stamps [ ] Medicaid/Children’s Health Insurance Program [ ] Earned Income Tax Credit
Number of children receiving childcare services						23h(6).
23i. Family services table
		(1) Need (Y or N)		(2) Need Met Through 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
23i (3) Service provider codes:
P = PHA T = TANF agency	D = DOL grantee V = Voluntary organization		PR = For profit entity N = Nonprofit agency		E = Employer C = Community college

23:	Family Self-Sufficiency (FSS)/MTW Self-Sufficiency Addendum
Note:	Complete this section if the family participates in the Family Self-sufficiency or an MTW self-sufficiency program. Line 23a:
Line 23b:	Check one category to indicate the purpose of the FSS Addendum.
Line 23c:	The effective date of the self-sufficiency action.
Line 23d:	The PHA code associated with the PHA that provides the self-sufficiency services.
Note:	For help obtaining the PHA’s identification number, contact the appropriate HUD field office.
Line 23e:	Reserved.
Line 23f:	Reserved.
Line 23g:	Reserved.
Line 23h.(1):	Indicate the head of household 's current employment status. Line 23h.(2):
Line 23h.(3):	Indicate the head of household’s current employment benefits. Check all that apply. Line 23h.(4):
Line 23h.(5):	Indicate whether or not the family receives additional assistance, such as food stamps, Medicaid, TANF assistance, or the earned income tax credit.
Line 23h.(6):	Indicate the number of children in the household who receive childcare services.
Line 23i.(1):	Indicate whether or not the PHA identified individual training and service needs of the family members.
Line 23i.(2):	If the PHA identified certain needs for family members, indicate whether or not the program meets these needs.
Line 23i.(3):	Using the codes provided at bottom of page, indicate the type of service provider that meets the participant’s need.

23j. Self-Sufficiency Contract Information
Initial start date (mm/yyyy) of contract of participation	23j(1).
Initial end date (mm/yyyy) of contract of participation	23j(2).
Contract date extended to (mm/yyyy) (if applicable)	23j(3).
Number of family members with Individual Training and Services Plan	23j(4).
Did the family receive selection preference because of a related service program participation? (Y or N)	23j(5).
23k. Escrow account information
Current account monthly credit	$ 23k(1).
Current account balance	23k(2).
Account amount disbursed to the family (cumulative as of end of reporting period)	23k(3).
23m. Exit information (complete only for exit report)
Did family complete FSS contract of participation or MTW self-sufficiency program? (Y or N)	23m(1).
If (1) is Yes, did family move to homeownership? (Y or N)	23m(2).
If (1) is No, reason for exit: [ ] Left voluntarily [ ] Asked to leave program [ ] Portability move-out [ ] Left because essential service was unavailable [ ] Contract expired but family did not fulfill obligations

23:	Family Self-Sufficiency (FSS)/MTW Self-Sufficiency Addendum (continued)
Line 23j.(1):	Enrollment report only. The effective date of the family’s contract of participation ; the date the family initially enrolled in the self-sufficiency program.
Line 23j.(2):	Enrollment report only. The expiration date of the family’s contract of participation; the date the family is initially expected to exit the self-sufficiency program.
Line 23j.(3):	If applicable, the date to which the PHA has extended the family’s contract of participation.
Line 23j.(4):	The number of family members in the household who have current Individual Training and Services Plans under the contract of participation.
Line 23j.(5):	For new enrollment, indicate whether or not the family received a selection preference due to participation in a related service program.
Line 23k.(1):	The current dollar amount credited to the family’s account due to increases in earned income by the family.
Line 23k.(2):	The current dollar amount of the family’s account based on the most recent report of account funds and activity.
Line 23k.(3):	Total dollar cumulative amount, if any, of all escrow disbursements ever made to the family.
Line 23m.(1):	Indicate if the family fulfilled all of its obligations under the contract during the contract term.
Line 23m.(2):	Indicate if the family completed the contract and is moving to homeownership.
Line 23m.(3):	Indicate why the family did not complete its FSS or MTW self-sufficiency contract.

Previous editions are obsolete

form HUD-50058 MTW (04/20xx)