Form HUD 50058 MTW (Une HUD 50058 MTW (Une Moving to Work Family Report

OMB Approval Number 2577-0083 (expires 06/30/2013)

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

MTW Family Report

Form HUD-50058 MTW, Family Report, applies to Moving to Work Public Housing and
Section 8 programs.
Additional instructions are contained in the Form HUD-50058 MTW Instruction Booklet.

Previous editions are obsolete

form HUD-50058 MTW (1/2001)

Public reporting burden for this collection of information is estimated to average 30 minutes per response in the first year, and 15 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.
Send the data to the electronic address required by HUD. Questions? Phone 1-800-FON-MTCS (1-800-366-6827) or go to the MTCS Web Site at
http://www.hud.gov/pih/systems/mtcs/pihmtcs.html.
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. 3601-19), and by the Omnibus ConsolidatedRescissions 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. This collection is mandatory. The information requested is required
to obtain and 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).
Sensitive Information: The information on these forms is sensitive and is protected by the Privacy Act. Keep the forms locked and confidential.

Acronyms

FSS
HAP
HQS
HUD
INS
OMB
PHA
SSA
SSI
SSN
TANF
TIN
TTP
MTW

=
=
=
=
=
=
=
=
=
=
=
=
=
=

Family Self-Sufficiency program
Housing Assistance Payment
Housing Quality Standards
U.S. Department of Housing & Urban Development
U.S. Immigration and Naturalization Services
U.S. Office of Management and Budget
Public Housing Agency
Social Security Administration
Supplemental Security Income
Social Security Number
Tenant Assistance for Needy Families
Taxpayer Identification Number
Total Tenant Payment
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. Reserved: HUD may have future directions about how to use these lines. Reserved lines are placeholders for future changes.
6. Calculation column is a scratch area where PHAs may perform manual calculations.
7. Leave blank any line(s) or item(s) that do not apply unless this Form instructs otherwise.
Previous editions are obsolete

i

form HUD-50058 MTW (1/2001)

Head of household name

MTW Family Report

Social Security Number

Date modified (mm/dd/yyyy)

U.S. Department of Housing and Urban Development

OMB Approval Number 2577-0083

Office of Public and Indian Housing

Expires 1/31/2007

1. MTW Agency
1a. Agency name

1a.

1b. PHA code

1b.

1c. Program

P = Public Housing
PR = Project-Based Assistance
T = Tenant-Based Assistance

1d. Project number (Public Housing only)

1c.
Suffix:

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.

1 = New Admission
2 = Annual Reexamination
3 = Interim Reexamination
4 = Portability Move-in
5 = Portability Move-out

6 = End Participation
7 = Other Change of Unit
8 = FSS/MTW Self-Sufficiency Only
9 = Annual Reexamination Searching
10 = Issuance of Voucher Equivalent

11 = Expiration of Voucher Equivalent
12 = Reserved
13 = Annual HQS Inspection Only
14 = Historical Adjustment
15 = Void

2b. Effective date (mm/dd/yyyy) of action

2b.

2c. Correction?

2c.

(Y or N)

2d. If correction: (check primary reason)

Family income correction
Family correction (non-income)

PHA income correction
PHA correction (non-income)

2e. Date correction transmitted (mm/dd/yyyy)

2e.

2f. Repayment agreement?

2f.

(Y or N)

2g. Monthly amount of repayment

$

2h. Date (mm/dd/yyyy) of admission to program

2g.
2h.

2i. Projected effective date (mm/dd/yyyy) of next reexamination

2i.

2j. Date (mm/dd/yyyy) of admission to Moving to Work program

2k.

2k. FSS participation now or in last year? (Y or N)

2k.

2m. MTW self-sufficiency program participation now or in last year? (Y or N)

2m.

2n. Reserved
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.

Previous editions are obsolete

2

form HUD-50058 MTW (1/2001)

Head of household name

Social Security Number

Date modified (mm/dd/yyyy)

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):
1:
Line 1a:

On every page, enter the date the PHA representative fills out the Form or modifies any Form page.

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.
For help obtaining the PHA’s identification number, contact the appropriate HUD field office, the HA Profiles Web
Site within PIC or the MTCS Hotline at 1-800-FON-MTCS.

Note:

MTW Agency
Name of the Public Housing Agency (PHA) that completes the family’s Form HUD-50058 MTW.

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, 3digit project number, and 3-digit suffix (if applicable).

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 2q-2u:
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.

Previous editions are obsolete

ii

form HUD-50058 MTW (1/2001)

Head of household name

Social Security Number

Date modified (mm/dd/yyyy)

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

3b. Last Name & Sr, Jr. etc.

3g. Sex

3h. Relation

3c. First name

3i. Citizenship

3d. MI

3j. Disability (Y/N)

3e. Date of birth

3k. Race

H

3f. Age on effective
date of action

=1

=2

=3

=4

3m. Ethnicity

=5

3n. Social Security Number

3p. Alien Registration Number
A-

3q. Meeting community service requirement? (Public Housing
only)

3r. Total years of school (0-25)

3a. Member
number
02

3b. Last Name & Sr, Jr. etc.

3g. Sex

3h. Relation

3c. First name

3i. Citizenship

3d. MI

3j. Disability (Y/N)

3e. Date of birth

3k. Race

3f. Age on effective
date of action

=1

=2

=3

=4

3m. Ethnicity

=5
3n. Social Security Number

3p. Alien Registration Number

3q. Meeting community service requirement? (Public Housing only)

A3r. Total years of school (0-25)

3a. Member
number
03

3b. Last Name & Sr, Jr. etc.

3g. Sex

3h. Relation

3c. First name

3i. Citizenship

3d. MI

3j. Disability (Y/N)

3e. Date of birth

3k. Race

3f. Age on effective
date of action

=1

=2

=3

=4

3m. Ethnicity

=5
3n. Social Security Number

3p. Alien Registration Number

3q. Meeting community service requirement? (Public Housing only)

A3r. Total years of school (0-25)

3a. Member
number
04

3b. Last Name & Sr, Jr. etc.

3g. Sex

3h. Relation

3c. First name

3i. Citizenship

3d. MI

3j. Disability (Y/N)

3e. Date of birth

3k. Race

3f. Age on effective
date of action

=1

=2

=3

=4

3m. Ethnicity

=5
3n. Social Security Number

3p. Alien Registration Number

3q. Meeting community service requirement? (Public Housing only)

A3r. Total years of school (0-25)

3a. Member
number
05

3b. Last Name & Sr, Jr. etc.

3g. Sex

3h. Relation

3c. First name

3i. Citizenship

3d. MI

3j. Disability (Y/N)

3e. Date of birth

3k. Race

3f. Age on effective
date of action

=1

=2

=3

=4

3m. Ethnicity

=5
3n. Social Security Number

3p. Alien Registration Number

3q. Meeting community service requirement? (Public Housing only)

A3r. Total years of school (0-25)

Codes:
3h.
H =
S =
K =
F =
Y =
E =
L =
A =

Relation:
head
spouse
co-head
foster child/foster adult
other youth under 18
full-time student 18+
live-in aide
other adult

Previous editions are obsolete

3i.
EC
EN
IN
PV

Citizenship:
= eligible citizen
= eligible noncitizen
= ineligible noncitizen
= pending verification

3k.
1 =
2 =
3 =
4 =
5 =

3

Race:
White
Black/African American
American Indian/Alaska Native
Asian
Native Hawaiian/Other Pacific Islander

3m. Ethnicity:
1 = Hispanic or Latino
2 = Not Hispanic or Latino
3q.
1
2
3
4
5

=
=
=
=
=
=

Community Service
yes
no
pending
exception
n/a

form HUD-50058 MTW (1/2001)

Head of household name

Social Security Number

Date modified (mm/dd/yyyy)

3:

MTW Household

Note:
Note:
Note:

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.

Line 3a:

The Member number identifies the individual listed on that line of the Form.

Line 3b:

Indicate 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:

Indicate the first name of each household member. Do not include name prefixes, such as Ms. or Mr.

Line 3d:

Indicate the middle initial of each household member. If no middle initial, leave blank. If more than one middle initial,
only enter one.

Line 3e:

Indicate the date of birth for each household member.

Line 3f:

Indicate 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 (M=Male, F=Female).

Line 3h:

Use code at bottom of page that best categorizes the relation or role of each household member.

Line 3i:

Use code at 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).
If family member does not know or have a SSN, enter 999-99-9999.

Note:
Line 3p:
Note:

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 Anumber 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:
Note:
Note:

Public Housing only. Use code at bottom of page to indicate whether the family member met his or her community
service requirements under PHRA.
The law requires an average of eight hours of community service per month during the year.
Use ‘5’ until the community service requirement comes into effect for your particular PHA.

Line 3r:
Note:

Enter the highest grade or the full years of formal schooling that the household member completed (0-25).
st
Years of schooling begin with 1 grade (do not count kindergarten or pre-school).

Line 3s:

Indicate whether additional household member information is included on an additional sheet of paper as an
attachment to the Form.

Previous editions are obsolete

iii

form HUD-50058 MTW (1/2001)

Head of household name

3a. Member
number

Social Security Number

3b. Last Name & Sr, Jr. etc.

3g. Sex

3h. Relation

Date modified (mm/dd/yyyy)

3c. First name

3i. Citizenship

3d. MI

3j. Disability (Y/N)

3e. Date of birth

3k. Race

3f. Age on effective
date of action

=1

=2

=3

=4

3m. Ethnicity

=5
3n. Social Security Number

3p. Alien Registration Number

3q. Meeting community service requirement? (Public Housing only)

A3r. Total years of school (0-25)

3a. Member
number

3b. Last Name & Sr, Jr. etc.

3g. Sex

3h. Relation

3c. First name

3i. Citizenship

3d. MI

3j. Disability (Y/N)

3e. Date of birth

3k. Race

3f. Age on effective
date of action

=1

=2

=3

=4

3m. Ethnicity

=5
3n. Social Security Number

3p. Alien Registration Number

3q. Meeting community service requirement? (Public Housing only)

A3r. Total years of school (0-25)

3a. Member
number

3b. Last Name & Sr, Jr. etc.

3g. Sex

3h. Relation

3c. First name

3i. Citizenship

3d. MI

3j. Disability (Y/N)

3e. Date of birth

3k. Race

3f. Age on effective
date of action

=1

=2

=3

=4

3m. Ethnicity

=5
3n. Social Security Number

3p. Alien Registration Number

3q. Meeting community service requirement? (Public Housing only)

A3r. Total years of school (0-25)

3a. Member
number

3b. Last Name & Sr, Jr. etc.

3g. Sex

3h. Relation

3c. First name

3i. Citizenship

3d. MI

3j. Disability (Y/N)

3e. Date of birth

3k. Race

3f. Age on effective
date of action

=1

=2

=3

=4

3m. Ethnicity

=5
3n. Social Security Number

3p. Alien Registration Number

3q. Meeting community service requirement? (Public Housing only)

A3r. Total years of school (0-25)

3a. Member
number

3b. Last Name & Sr, Jr. etc.

3g. Sex

3h. Relation

3c. First name

3i. Citizenship

3d. MI

3j. Disability (Y/N)

3e. Date of birth

3k. Race

3f. Age on effective
date of action

=1

=2

=3

=4

3m. Ethnicity

=5
3n. Social Security Number

3p. Alien Registration Number

3q. Meeting community service requirement? (Public Housing only)

A3r. Total years of school (0-25)

Codes:
3h.
H =
S =
K =
F =
Y =
E =
L =
A =

Relation:
head
spouse
co-head
foster child/foster adult
other youth under 18
full-time student 18+
live-in aide
other adult

3i.
EC
EN
IN
PV

Citizenship:
= eligible citizen
= eligible noncitizen
= ineligible noncitizen
= pending verification

3s. Continued on an additional sheet?

Previous editions are obsolete

3k.
1 =
2 =
3 =
4 =
5 =

Race:
White
Black/African American
American Indian/Alaska Native
Asian
Native Hawaiian/Other Pacific Islander

3m. Ethnicity:
1 = Hispanic or Latino
2 = Not Hispanic or Latino
3q.
1
2
3
4
5

=
=
=
=
=
=

Community Service
yes
no
pending
exception
n/a

(Y or N)

3s.

4

form HUD-50058 MTW (1/2001)

Head of household name

Social Security Number

Date modified (mm/dd/yyyy)

3:

MTW Household

Note:
Note:
Note:

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.

Line 3a:

The Member number identifies the individual listed on that line of the Form.

Line 3b:

Indicate 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:

Indicate the first name of each household member. Do not include name prefixes, such as Ms. or Mr.

Line 3d:

Indicate the middle initial of each household member. If no middle initial, leave blank. If more than one middle initial,
only enter one.

Line 3e:

Indicate the date of birth for each household member.

Line 3f:

Indicate 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 (M=Male, F=Female).

Line 3h:

Use code at bottom of page that best categorizes the relation or role of each household member.

Line 3i:

Use code at 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).
If family member does not know or have a SSN, enter 999-99-9999.

Note:
Line 3p:
Note:

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 Anumber 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:
Note:
Note:

Public Housing only. Use code at bottom of page to indicate whether the family member met his or her community
service requirements under PHRA.
The law requires an average of eight hours of community service per month during the year.
Use ‘5’ until the community service requirement comes into effect for your particular PHA.

Line 3r:
Note:

Enter the highest grade or the full years of formal schooling that the household member completed (0-25).
st
Years of schooling begin with 1 grade (do not count kindergarten or pre-school).

Line 3s:

Indicate whether additional household member information is included on an additional sheet of paper as an
attachment to the Form.

Previous editions are obsolete

iv

form HUD-50058 MTW (1/2001)

Head of household name

Social Security Number

Date modified (mm/dd/yyyy)

3t. Total number in household

3t.

3u. Family subsidy status under noncitizen rule: C = Qualified for continuation of full assistance

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.

E = Eligible for full assistance
F = Eligible for full assistance pending verification of status
P = Prorated assistance

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
4e. Continuously assisted under the 1937 Housing Act?

(Y or N)

4e.

4f. Reserved

5. MTW Unit To Be Occupied on Effective Date of Action
5a. Unit address
Number and street

Apt.

City

State

5b. Is mailing address same as unit address?

Zip code (+4)

(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)

5f.

(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 (Tenant-Based or Project-Based Assi stance 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

Low-rise

High rise with elevator

Rowhouse/townhouse
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.

Previous editions are obsolete

5

form HUD-50058 MTW (1/2001)

Head of household name

Social Security Number

Date modified (mm/dd/yyyy)

3:

MTW Household (continued)

Line 3t:
Note:

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.

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.
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.

Note:
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 Background at Admission

Line 4a:
Note:

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).

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:
Note:

The complete address where the family receives mail, if other than the unit address indicated in line 5a.
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.
This date may be different from the date unit last passed HQS inspection (line 5h) if the unit failed the last HQS
inspection.

Note:
Line 5j:
Note:

Tenant-Based or Project-Based Assistance only. Indicate the year that the unit was built.
This date is found on the request for tenancy approval form.

Line 5k:
Note:
Note:

Section 8 only. Indicate the building structure type.
See the Instruction Booklet for descriptions of each housing type.
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.

Previous editions are obsolete

v

form HUD-50058 MTW (1/2001)

Head of household name

Social Security Number

Date modified (mm/dd/yyyy)

18. MTW Asset Income
18a. Family member
name

No.

18b.Type of asset
(PHA use)

18c.Calculation
(PHA use)

18d. Cash value of
asset

18e. Anticipated
Income

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

18g.

18h. Passbook rate (written as decimal)

$

0.

18h.

18i. Imputed asset income: 18f X 18h (if 18f is $5000 or less, put 0)

$

18i.

18f, 18g Column totals

18f.

18j. Final asset income: larger of 18g or 18i

$

18j.

19. MTW Income
19a. Family member
name

No.

19b. Income
code

19c. Calculation
(PHA use)

19g, 19h. Column totals

19d. Dollars per year

19e. Income
exclusions

19f. Income after
exclusions
(19d minus 19e)

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

19i.

Total annual income: 18j + 19h

19j.

Deductions

19g.
$

19k. Adjusted annual income: 19i minus 19j
19b.
Income Code
Wages:
B = own business
F = federal wage
HA = PHA wage
M = military pay
W = other wage

Previous editions are obsolete

$

Welfare:
G = general assistance
IW = annual imputed welfare income
T = TANF assistance

SS/SSI/Pensions:
P = pension
S = SSI
SS = Social Security

6

19h.
$

19i.

$

19k.

19j.

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

form HUD-50058 MTW (1/2001)

Head of household name

Social Security Number

Date modified (mm/dd/yyyy)

18:

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:
Note:

List any asset that has a dollar value or provides a source of income to the person listed in column 18a.
See the Form HUD 50058 MTW 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.

Line 18f:

Total of the values listed in column 18d.

Line 18g:

Total of the values listed in column 18e.

Line 18h:
Note:

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.

Line 18i:
Note:

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.

Line 18j:

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 12-month 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:
Note:

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 MTW Instruction Booklet for a detailed description of each income code.

Line 19c:

Use this column to perform income calculations.

Line 19d:
Note:

Annual income amount the family member earns from the income source(s) listed.
See the Form HUD-50058 MTW Instruction Booklet for a description of each income source.

Line 19e:
Note:
Note:

Income excluded from annual income calculations.
Includes income disallowance and individual savings accounts (ISA) for Public Housing.
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).

Previous editions are obsolete

vi

form HUD-50058 MTW (1/2001)

Head of household name

Social Security Number

Date modified (mm/dd/yyyy)

20. MTW Public Housing
20a. Type of rent

Income-based

Flat

20b. Tenant rent

$

20b.

20c. Mixed family tenant rent

$

20c.

20d. Utility allowance/estimate

$

20d.

20e. Is this a ceiling rent? (Y or N)

20f.

20f. Reserved

21. MTW Tenant-Based or Project-Based Assistance
21a. Indicate if flat subsidy or income-based subsidy

Income-based

Flat

21a.

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

Previous editions are obsolete

7

form HUD-50058 MTW (1/2001)

Head of household name

Social Security Number

Date modified (mm/dd/yyyy)

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:
Note:

Indicate whether the family pays an income based rent or a flat rent.
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:
Note:

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.
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.

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:
Note:

Indicate whether the family pays an income based subsidy or a flat subsidy.
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), on-going administrative
fee, and any utility reimbursement to the family.
Enter 0 if the family was absorbed by the receiving PHA.

Note:
Line 21f:
Note:

The initial PHA’s 2-letter state code and 3-digit identification number.
For help obtaining the initial PHA’s identification number, contact the appropriate HUD field office, the HA Profiles
Web Site within PIC or the MTCS Hotline at 1-800-FON-MTCS.

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:
Note:

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.
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.

Previous editions are obsolete

vii

form HUD-50058 MTW (1/2001)

Head of household name

Social Security Number

Date modified (mm/dd/yyyy)

22. MTW Homeownership
22a.

Indicate if flat subsidy or income-based subsidy
Income-based
Flat

22a.

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.

22f.

PHA code billed

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.

22k. Flat subsidy amount
22m. Total family share

$

22m.

22n. Mixed family total family share

$

22n.

22p. Is this a ceiling family share? (Y or N)

22p.

22q. Reserved

Previous editions are obsolete

8

form HUD-50058 MTW (1/2001)

Head of household name

Social Security Number

Date modified (mm/dd/yyyy)

22:

MTW Homeownership

Note:

Complete if program type is Homeownership (line 1c=PR) or (line 1c=T) 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:
Note:

Indicate if flat subsidy or income-based subsidy.
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, on-going
administrative fee, and any utility reimbursement to the family.
Enter 0 if the family was absorbed by the receiving PHA.

Note:
Line 22f:
Note:

The initial PHA’s 2-letter state code and 3-digit identification number.
For help obtaining the initial PHA’s identification number, contact the appropriate HUD field office, the HA Profiles Web
Site within PIC or the MTCS Hotline at 1-800-FON-MTCS.

Line 22g:
Note:

The monthly homeownership cost.
Includes principal and interest on initial mortgage debt, taxes and insurance (PITI) and any mortgage insurance premium
(MIP), if applicable.

Line 22h:
Note:

The PHA’s utility allowance for the unit.
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.

Line 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.

Previous editions are obsolete

viii

form HUD-50058 MTW (1/2001)

Head of household name

Social Security Number

Date modified (mm/dd/yyyy)

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

Participate in special program? (check no more than one)

FSS

MTW self-sufficiency

23b.

Report category (check no more than one)

23c.

Effective date (mm/dd/yyyy) of self-sufficiency action

23c.

23d.

PHA code of PHA administering contract

23d.

23e.

Reserved

23f.

Reserved

23g.

Reserved

23h.

General Information

Enrollment

Progress

Exit

(1) 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

(2) Date (mm/dd/yyyy) current employment began

23h(2).

(3) Benefits in current employment: (check all that apply)

Hea lth

Retirement account

Other

(4) Reserved

23h(4).

(5) Assistance received by the family: (check all that apply)
TANF Income Assistance?

General Assistance?

Medicaid/Children’s Health Insurance Program?

Earned Income Tax Credit?

Food Stamps?

(6) Number of children receiving child care services
23i.

23h(6).

Family services table
(1) Need
(Y or N)

(2) Needs 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

Previous editions are obsolete

D = DOL grantee
V = Voluntary organization

PR = For profit entity
N = Nonprofit agency

9

E = Employer
C = Community college

formHUD-50058 MTW (1/2001)

Head of household name

Social Security Number

Date modified (mm/dd/yyyy)

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:

Identify if the family participates in a Family Self-Sufficiency (FSS) program or an MTW self-sufficiency program.

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:
Note:

The PHA code associated with the PHA that provides the self-sufficiency services.
For help obtaining the PHA’s identification number, contact the appropriate HUD field office, the HA Profiles Web Site
within PIC or the MTCS Hotline at 1-800-FON-MTCS.

Line 23e:

Reserved.

Line 23f:

Reserved.

Line 23g:

Reserved.

Line 23h.(1):

Indicate the head of household 's current employment status.

Line 23h.(2):

The date the head of household began his/her current job.

Line 23h.(3):

Indicate the head of household’s current employment benefits. Check all that apply.

Line 23h.(4):

Reserved.

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.

Previous editions are obsolete

ix

form HUD-50058 MTW (1/2001)

Head of household name

23j.

23k.

Social Security Number

Date modified (mm/dd/yyyy)

Self-Sufficiency Contract Information
(1) Initial start date (mm/yyyy) of contract of participation

23j(1).

(2) Initial end date (mm/yyyy) of contract of participation

23j(2).

(3) Contract date (mm/yyyy) extended to (if applicable)

23j(3).

(4) Number of family members with Individual Training and Services Plan

23j(4).

(5) Did the family receive selection preference because of a related service program participation?
(Y or N)

23j(5).

Escrow Account Information
(1) Current account monthly credit

$

23k(1).

(2) Current account balance

$

23k(2).

(3) Account amount disbursed to the family (cumulative as of end of reporting p eriod)

$

23k(3).

23m. Exit Information (complete only for Exit Report)
(1) Did family complete FSS contract of participation or MTW self-sufficiency program?
(2) If (1) is Yes, did family move to homeownership?
(3) If (1) is No, reason for exit:

(Y or N)

Left voluntarily

Asked to leave program

Left because essential service was unavailable

Previous editions are obsolete

(Y or N)
Portability move-out

Contract expired but family did not fulfill obligations

10

form HUD-50058 MTW (1/2001)

Head of household name

Social Security Number

Date modified (mm/dd/yyyy)

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

x

form HUD-50058 MTW (1/2001)