Note: The fields in the page heading are provided for the convenience of PHAs that maintain paper records of the Form HUD-50058.
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 completes the Form.
Note: Since codes submitted to the system may change over time or differ from other versions of the HUD-50058, the codes for the options listed in these instructions can be found in the Technical Reference Guide (TRG) on the Housing Information Portal (HIP) Technical Information page.
1. Agency
Line 1a: Name of the Public Housing Agency (PHA) that completes the family’s Form HUD-50058.
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.
Note: For help obtaining the PHA’s identification number, contact the appropriate HUD field office.
Line 1c: Using the options provided, indicate the housing assistance program in which the family participates. Note that H = Homeownership is for traditional homeownership vouchers, not Local, Non-Traditional Homeownership. The Local Non-Traditional Homeownership program is not applicable in the MTW expansion.
1c Programs: Public Housing Tenant-based Voucher Project-based Voucher Homeownership Voucher Local, Non-Traditional Property-Based Local, Non-Traditional Tenant-Based |
Line 1d: Public Housing only. The project number is composed of the 2-letter project state code, 3-digit PHA number, and 6-digit development number (if applicable).
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.
Line 1h: Unit Real Estate ID Number established by the system for the unit. Currently Public Housing only; may be used for other programs in the future.
2. Action
Line 2a: Use the applicable option provided below to report the family’s type of action.
Note: When a family that receives flat rent requires a full reexamination, use Annual Reexamination (2a= 2).
Note: Use Household Composition Change Only when household composition has changed but the family will not receive an interim reexamination (e.g., because their adjusted income increased by less than 10%).
Note: Use PBV Transfer to Tenant-Based Voucher to note when a family participating in the PBV program exercises their right to move with a tenant-based voucher.
Note: Use Other Change, Non-Income Threshold to note other changes when an annual or interim income reexamination is not performed. For example, use this action type to note contract rent changes, payment standard changes, and when families with tenant-based vouchers move out of their unit but continue to be program participants.
Line 2b: Date the reported action becomes effective.
Note: The effective date cannot be earlier than the date of admission to the program (line 2h).
Line 2c: Allows PHAs to correct fields previously transmitted in error.
Note: Use a correction for a minor change to a previously submitted record.
Line 2d: Indicate the primary reason for the correction record.
Line 2h: Date the PHA initially admitted the family into the program reported in line 1c.
Line 2i: The projected effective date of the family’s next reexamination.
Line 2j: Public Housing flat rent only. Projected effective date of the next flat rent annual update.
Line 2k: Indicate if the family currently participates or participated in a supportive services program in the past year (see Section 17).
Line 2m: Vouchers only. Indicate if the family receives an Enhanced Voucher using the options provided below.
Line 2n: Indicate if the family participates in a special program.
Note: Please reference the Special Program Codes list for the current options
Line 2q-2u: PHAs may use these lines for any information they wish to collect.
Line 2v: Indicate if the family currently participates or participated in an MTW self-sufficiency program in the past year.
Note: HUD encourages PHAs to use lines 2q through 2u for local initiatives.
Line 2w: If line 2a is End Participation, indicate the primary reason the family ended their participation in the program per the options below.
Line 2x: If line 2a is Interim Reexamination, indicate the reason there has been a change to the family’s information at a time other than a full reexamination or change of unit per the options below, selecting all that apply.
Line 2y: If this is a Voucher Issuance, use the options below to report the type.
Line 2z: Vouchers only. Enter the date (MM/DD/YYYY) that the HCV participant(s) vacated the unit but remains a program participant and is searching for a unit.
Line 2aa: PHAs should not use this field unless requested by HUD in support of a specific research need.
Line 2ab: PHAs should not use this field unless requested by HUD in support of a specific research need.
2a. Type of action New Admission Full Reexamination Interim Reexamination Portability Move-in (T and H only) Portability Move-out (T and H only) End Participation Unit Change Only FSS/MTW Self-Sufficiency Addendum Only Annual Reexamination Searching Issuance of Voucher (T only) Expiration of Voucher (T only) Flat Rent Annual Update (P only) Inspection Only (T and PR only) Void Household Composition Change Only PBV Transfer to Tenant-Based Voucher Other Change, Non-Income Threshold
2m. Special program Enhanced Voucher |
2w. End of Participation reason Changed program (non-RAD) Changed program due to RAD conversion Death of sole family member Absence from unit Nonpayment of rent Evicted by landlord PHA initiated - Criminal activity PHA initiated - Family is over-income (Public Housing) or exceeds 180 days of zero HAP (HCV) PHA initiated – Over asset limit Reached term limit PHA initiated – Other reasons (e.g., violation of lease or program rules) Tenant initiated – Family financial situation improved Tenant initiated – Dissatisfied with unit/PHA Tenant initiated - Other reasons
|
2x. Interim Reexamination reason Alternative rent hardship starting or ending Stepped rent update without income reexamination Decreased income (not an alternative rent hardship request) Increased income Household composition change Contract rent change Public housing over-income status 2y. Type of Voucher Issuance New Participant Port In Port Out Transfer of Unit |
3. 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: Select the option listed below that indicates the gender identity provided for each household member.
Line 3h: Select the option below that best categorizes the relation or role of each household member.
Line 3i: Select the option below that indicates each household member’s United States citizenship status.
Line 3j: Indicate whether or not the household member has a disability.
Line 3k: Select the option or options below that the family says best indicates each household member’s race. Select as many options as appropriate.
Line 3m: Select the option below that 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).
Note: If a head of household or household member does not have a SSN, see the Form HUD-50058 Instruction Booklet.
Line 3o: If any special status codes are applicable to this household member, enter them here. (Note: This field is in development and collection may be delayed until revisions to multiple systems are completed.)
Line 3p: Enter the Alien Registration Number issued to each noncitizen household member, if applicable.
Note: The Al number contains seven, eight or nine numerical digits preceded by the letter A, e. g., A72 735 827. If the A-number has seven digits, enter two zeros before the numbers. If the A-number has eight digits, enter one zero before the numbers. If the A-number has nine digits, enter the number without a leading zero. Do not enter the letter A in any case.
Line 3q: Public Housing only. Select the option below to indicate whether the family member met his or her community service or self-sufficiency requirement under PHRA.
Note: The law requires an average of eight hours of community service per month during the year.
Line 3r: Select the option below that corresponds to the average number of hours worked per week, over the past year.
Line 3s: Select the option below that corresponds to what extent the household is in compliance with the PHA’s work requirements policy, if applicable.
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: Select the option below 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).
3g. Gender: Male Female Other/Non-Binary/Gender Non-Conforming 3h. Relation: Head Spouse Co-head Foster child/foster Adult Other youth under 18 Full-time student 18+ Live-in aide Other adult
3i. Citizenship: Eligible citizen Eligible noncitizen Ineligible noncitizen Pending verification |
3k. Race: White Black/African American American Indian/Alaska Native Asian Native Hawaiian/Other Pacific Islander Some Other Race
3m. Ethnicity: Hispanic or Latino Not Hispanic or Latino
3o. Special Status: Children live in unit less than 50% of the time. Children live in the unit at least 50% of the time and receive a dependent deduction. Children who live in the unit at least 50% of the time and do not receive a dependent deduction.
3q. Community service or self-sufficiency: Yes No Pending Exempt |
3r. Average number of hours worked per week: 0 hours 1-10 hours/week 11- 20 hours/week 21-30 hours /week 31-40 hours/week More than 40 hours/week
3s. Work requirement compliance: In compliance Exempt Receiving a hardship Not in compliance, in probationary period and not subject to penalties Not in compliance, subject to penalties Not applicable, no work requirement policy
3u. Family subsidy status: Qualified for continuation of full assistance Eligible for full assistance Eligible for full assistance pending verification of status Prorated assistance
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4. Background at Admission
Line 4a: Date the PHA placed the family on the waiting list for the program under which they currently receive housing assistance.
Note: This date must not be later than effective date of action (line 2b).
Line 4b: Date the PHA selected the family from the waiting list.
Line 4c: The 5-digit ZIP code (+ 4, if applicable) where the family lived before admission to an assistance program.
Line 4d: Indicate whether or not the family was homeless at the time the PHA admitted the family to a housing assistance program. For the definition of homeless please see PIH Notice 2013-15.
Line 4e: Indicate whether the family was formerly homeless and living in a permanent or temporary housing situation following homelessness.
Line 4f: Vouchers only. Indicate whether or not the family qualified for program admission even though their income exceeds the very low-income limit (50% of the area’s median income).
Line 4g: 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 4h: Indicate whether the family is transitioning out of an institutional setting.
Line 4i: Indicate whether the family was a special admission.
5. 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). Urbanization applies only for addresses in Puerto Rico and denotes an area, sector, or residential development within a geographic area.
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(1): PBV only. Indicate if the unit the family occupies on the effective date of action (line 2b) is accessible..
Line 5e(2): PBV only. If line 5e(1) is Yes, use the options below to indicate the type of accessible unit the family occupies on the effective date of action (line 2b).
Hearing/Visual Impairment – Section 504: These are units that comply with the accessibility requirements specified in 24 CFR part 8 and HUD’s accessibility standard including UFAS, HUD’s Deeming Notice, or other alternative accessibility standards articulated in 24 CFR part 8 as applicable to units for persons with hearing or vision impairments.
Mobility Impairment – Section 504: These are units that comply with the accessibility requirements specified in 24 CFR part 8 and HUD’s accessibility standard including UFAS, HUD’s Deeming Notice, or other alternative accessibility standards articulated in 24 CFR part 8 as applicable to units for persons with mobility impairments.
Partially Accessible: The term Partially Accessible refers to a unit that is located on an accessible route and has some accessibility features but does not meet either the Mobility Impairment or Hearing/Visual Impairment standards. specified above.
Not Accessible: The term Not Accessible refers to all units that are not designated otherwise in this category. This is the default category for all units.
Line 5f(1): Public Housing and PBV only. Indicate whether or not the family requested disability amenities or accessibility features.
Line 5f(2): Public Housing and PBV only. If line 5f(1) is Yes, use the options below to indicate the type of accessibility features the family requested.
Hearing/Visual Impairment – Section 504: These are units that comply with the accessibility requirements specified in 24 CFR part 8 and HUD’s accessibility standard including UFAS, HUD’s Deeming Notice, or other alternative accessibility standards articulated in 24 CFR part 8 as applicable to units for persons with hearing or vision impairments.Mobility Impairment – Section 504: These are units that comply with the accessibility requirements specified in 24 CFR part 8 and HUD’s accessibility standard including UFAS, HUD’s Deeming Notice, or other alternative accessibility standards articulated in 24 CFR part 8 as applicable to units for persons with mobility impairments.
Partially Accessible: The term Partially Accessible refers to a unit that is located on an accessible route and has some accessibility features but does not meet either the Mobility Impairment or Hearing/Visual Impairment standards specified above.
Not Accessible: The term Not Accessible refers to all units that are not designated otherwise in this category. This is the default category for all units.
Line 5g: Public Housing and PBV 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: Section 8 only, except Homeownership. The last date the unit passed an inspection.
Line 5i: Section 8 only, except Homeownership. The last date a PHA inspector performed a full inspection of the unit listed on line 5a.
Line 5j: Was the last passed inspection an alternative inspection?
Note: This date may be different from the date unit last passed inspection (line 5h) if the unit failed the last HQS inspection.
Line 5k: Section 8 only. The year that the unit was built.
Note: This date is found on the request for tenancy approval form.
Line 5l: Section 8 only. The building structure type.
Note: See the Instruction Booklet for descriptions of each housing type.
5e(1). PHA identified unit as accessible Yes No
5e(2). Type of accessibility features Hearing/Vision Mobility Both Partially |
5f(1). Family requested accessibility features Yes No
5f(2). Type of accessibility features requested Hearing/Vision Mobility Both Partially
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6. Assets
Note: Use a separate line for each family member and asset type. Include all net family assets and any assets excluded from net family assets for which the family must report actual asset income.
Line 6a: 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 6b: List all assets that have a dollar value or provides a source of income to the person listed in column 6a.
Note: See the Form HUD-50058 Instruction Booklet for an explanation of allowable assets.
Line 6c: For each asset, indicate whether the asset is included in net family assets.
Note: PHAs need to determine whether the combined value of the family’s non-necessary personal property will be excluded from net family assets before responding. When the combined value is excluded, mark “N” for each asset of non-necessary personal property.
Line 6d: Estimated, known or calculated dollar value of the asset listed.
Line 6e: Actual income for the 12-month period under examination from the asset listed.
Line 6f: Estimated imputed income for the 12-month period under examination from the asset listed.
Line 6g: Total value of net family assets. The total value should equal the sum of only the values in column 6d corresponding to assets included in net family assets, as indicated in column 6c.
Line 6h: Total of the values listed in column 6e.
Line 6i: Total of the values listed in column 6f.
Line 6j: Enter the passbook rate as a decimal.
Line 6k: Total amount of household income derived from assets.
7. Income
Note: If the family members do not have any income from sources other than assets and do not have or expect any other income in the 12-month period under examination, leave 7a through 7g blank. Fill in total annual income (line 7i), which would be the total of the asset income.
Line 7a: 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 7b: Use the option below that represents the type of income for a family member.
Note: See the Form HUD-50058 Instruction Booklet for a detailed description of each income code.
Line 7c: Use this column to perform income calculations.
Line 7d: Yearly income amount the family member receives from the income source(s) listed.
Note: See the Form HUD-50058 Instruction Booklet for a description of each income source.
Line 7e: Income excluded from annual income calculations.
Note: Includes income disallowance and individual savings accounts (ISA) for Public Housing.
Note: See the Form HUD-50058 Instruction Booklet for a description of each income exclusion.
Line 7f: The family’s total income minus any exclusions. Take dollars per year (line 7d) minus income exclusions (line 7e).
Line 7g: The total of the dollar amounts listed in column 7f.
Line 7h: Indicate whether prior year or current/actual income has been entered in this section.
Line 7i: The family’s total annual income. Add the final asset income (line 6k) and the total income after income exclusions (line 7g).
Line 7j: 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 7k: Indicate if the family’s total annual income (7i) exceeds the over-income limit.
Line 7l: Line 7l should only be completed if “Y” is selected in 7k. Indicate when the family first began the 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 grace period and subsequently exceeds it again, the grace period starts over.
7b. Income:
Wages: Own business Federal wage PHA wage Military pay Other wage |
Welfare: General assistance Annual imputed welfare income TANF assistance
SS/SSI//SSDI/Pensions: Pension SSI Social Security Social Security Disability Insurance |
Other Income Sources Child support Medical reimbursement Indian trust/per capita Other nonwage sources Unemployment benefits Safe harbor determination |
8. Deductions and Allowances
Line 8a: The family’s total annual family income. Copy from 7i.
Line 8b: The name of each family member in the household, and their individual Member number as provided in line(s) 3a that corresponds to the income information reported.
Line 8c: The type of persmissive deduction as determined by the PHA.
Line 8d: The amount of the permissive deduction.
Line 8e: The total of the dollar amounts (permissive deductions) listed in column 8d.
Note: If the head of household and spouse or co-head are under age 62, and there are no family members with a disability, skip to line 8k. Otherwise, enter all medical expense information for the entire family in lines 8f through 8n.
Line 8f: Amount of unreimbursed health and medical and reasonable attendant care and auxiliary apparatus expenses that the family must pay before the PHA can deduct an allowance for such expenses from their income. Multiply 0.10 by total annual income (line 8a).
Line 8g: The family’s total annual unreimbursed reasonable attendant care and auxiliary apparatus expenses (for families that include a person with disabilities).
Line 8h: The amount the PHA may potentially deduct for the family’s reasonable attendant care and auxiliary apparatus expenses. Subtract the medical/ disability threshold (line 8f) from the total unreimbursed disability assistance expenses (line 8g).
Note: If the maximum disability allowance is negative and head/spouse/co-head is under 62 and not disabled, enter 0.
Note: If the maximum disability allowance is negative and head/spouse/co-head is elderly or disabled, copy the total unreimbursed disability assistance expenses (line 8g).
Line 8i: Of a family’s dollars per year listed in line 7d, determine the earned amount made possible by the unreimbursed reasonable attendant care and auxiliary apparatus expenses the family incurs.
Line 8j: The total reasonable attendant care and auxiliary apparatus expense amount the family may deduct. Lower of the maximum disability allowance (line 8h) or the earnings made possible by disability assistance expense (line 8i).
Note: If the total unreimbursed reasonable attendant care and auxiliary apparatus expense (line 8g) is less than the medical/disability threshold (line 8f), and head/spouse/co-head is elderly or disabled, copy the maximum disability allowance (line 8h).
Line 8k: The total annual amount of the family’s health and medical expenses that another source does not reimburse (e. g., co- payments for medical insurance).
Note: If the head/spouse/co-head is under 62 and not disabled, enter 0.
Line 8l: Using the options below, indicate whether the family is eligible for a hardship exemption for health and medical care expenses and reasonable attendant care and auxiliary apparatus expenses, a hardship exemption to continue childcare expenses, both, or neither.
8l. Medical or Child Care Expense Hardship: Medical Hardship Child care Hardship Medical and Child care Hardships Not Applicable |
Line 8m: The amount of the family’s total disability assistance (line 8j) and medical expenses (line 8k).
Note: If no reasonable attendant care and auxiliary apparatus expenses, copy the total unreimbursed medical expenses (line 8k).
Line 8n: The amount of the family’s allowance for health and medical expenses and reasonable attendant care and auxiliary apparatus expenses.
Note: If the family does not have any reasonable attendant care and auxiliary apparatus expenses or if the total unreimbursed reasonable attendant care and auxiliary apparatus expenses (line 8g) is less than the medical/disability threshold (line 8f), enter the total reasonable attendant care and auxiliary apparatus and health and medical expenses (line 8m) minus the medical/disability threshold (line 8f). If the difference is negative, put zero.
Note: If there are reasonable attendant care and auxiliary apparatus expenses and the total unreimbursed reasonable attendant care and auxiliary apparatus expenses (line 8g) are greater than or equal to the medical/disability threshold (line 8f), copy the total reasonable attendant care and auxiliary apparatus and health and medical expenses (line 8m).
Line 8p: The family’s standard allowance amount if the head of household or spouse or co-head is elderly (age 62 or over), or disabled. The allowance changes periodically to reflect inflation. See the HUD website for the current allowance level.
Line 8q: The total number of dependents who live in the household and are under 18 years of age, or have a disability, or are full-time students of any age.
Line 8r: Standard allowance amount for each dependent in the household.
Note: The allowance per dependent changes periodically to reflect inflation. See the HUD website for the current allowance level.
Line 8s: The amount of the family’s dependent allowance. Multiply the number of dependents (line 8q) in the household by the standard allowance per dependent amount (line 8r).
Line 8t: The household’s total yearly unreimbursed childcare expenses.
Note: This is the estimated amount a family expects to pay for childcare during the annual income period.
Line 8u: The total amount of deductions and allowances not reflected on other lines in this section. These would include those covered in waivers per the MTW Operations Notice. Also, to be used for Local, Non-Traditional Property-Based and Local, Non-Traditional Tenant-Based programs.
Line 8x: The total amount of all of the family’s allowances. Enter the sum of lines 8e, 8n, 8p, 8s, 8t, and 8u.
Line 8y: The family’s adjusted annual income. Subtract total allowances (line 8x) from total annual income (line 8a).
Note: If 8u or 8x is larger, put 0.
9. Total Tenant Payment (TTP)
Line 9a: Divide total annual income (line 8a) by 12 to get total monthly income.
Line 9c: Multiply total monthly income (line 9a) by 0.10 to get total tenant payment (TTP) based on annual income.
Line 9d: Divide adjusted annual income (line 8y) by 12 to get adjusted monthly income.
Line 9e: Percentage of adjusted monthly income used to determine total tenant payment (TTP).
Line 9f: Multiply the adjusted monthly income (line 9d) by percentage of adjusted monthly income (line 9e) and divide by 100 to get total tenant payment (TTP) based on adjusted monthly income.
Line 9g: The amount the welfare assistance agency specifically designates for shelter and utilities if the family receives welfare assistance. The welfare assistance agency may adjust this amount in accordance with the actual cost of shelter and utilities.
Note: If no welfare rent, put 0.
Line 9h: Enter the PHA established monthly minimum rent amount. The PHA may require the tenant to pay a minimum rent amount up to $50.
Note: If the PHA waived this payment because of financial hardship, enter 0.
Line 9i: Enhanced Vouchers only. Enter the monthly rent that the family was paying on the date of the ‘eligibility event’ for the project.
Line 9j: The total tenant payment (TTP). The highest amount listed in the lines 9c, 9f, 9g, 9h, or 9i.
Line 9k: The most recent total tenant payment (TTP) amount for the family.
Note: This amount is only available if the family previously lived in subsidized housing.
Line 9m: Indicate if the family qualifies for a minimum rent hardship exemption.
Note: Under PHRA, a family does not have to pay the PHA established minimum rent if they qualify for a financial hardship exemption.
10. Public Housing
Note: Complete if the family participates in the Public Housing program (line 1c=P) and the type of action is New Admission (2a= 1), Annual Reexamination (2a= 2), Interim Reexamination (2a= 3), or Unit Change Only (2a= 7).
Line 10a: The total tenant payment (TTP). Copy from 9j.
Line 10b: Flat rent dollar amount.
Note: Flat rent is set by the unit size and building.
Note: When authorized to administer ceiling rents, PHAs must set ceiling rents at the level required for flat rents.
Line 10d: The lesser amount of either the total tenant payment (TTP) (line 10a) or flat rent, if the PHA is authorized to administer an income based ceiling rent (line 10b).
Note: If the PHA is not authorized to administer an income based ceiling rent, do not compare 10a and 10b; enter the TTP (line 10a).
Line 10e: If the payment does not include all utilities, the monthly allowance amount for tenant supplied utilities that apply to the family occupied unit.
Note: If there is no utility allowance, enter 0.
Line 10f: The rent amount the family pays to the owner after deducting the utility allowance (line 10e) from the lower rent (line 10d) or the total credit amount the family receives to pay utilities.
Line 10h: The maximum rent. To calculate the maximum rent, list the total tenant payments (TTP) paid by all tenants in this size unit in the PHA’s jurisdiction from largest to smallest, then take the TTP that falls at the 95th percentile.
Line 10i: Maximum amount of rent subsidy available to the family. Subtract total tenant payment (TTP) (line 10a) from the Public Housing maximum rent (line 10h).
Line 10j: The total number of family members eligible for rent subsidy based on the Noncitizens Rule.
Line 10k: The total number of family members in the household.
Note: Include all family members, including ineligible noncitizen family members (3i= IN). Do not include live-in aides or foster children/adults.
Line 10n: The total amount of rent subsidy for which the family is eligible. Divide family maximum subsidy (line 10i) by the total number in the family (line 10k) and multiply the product by the total number eligible (line 10j).
Line 10p: The mixed family total tenant payment (TTP) for the unit based on the proration calculation. Public Housing maximum rent (line 10h) minus eligible subsidy (line 10n).
Line 10r: If the payment does not include all utilities, the monthly allowance amount for tenant supplied utilities that apply to the family occupied unit.
Note: If there is no utility allowance, enter 0.
Line 10s: The rent amount the family pays to the owner after deducting the utility allowance (line 10r) from the mixed family total tenant payment (TTP) (line 10p), or the total credit amount the family receives to pay for utilities.
Line 10u: Select the type of rent the family selected from the options listed below.
Line 10w: The rent amount the family pays when an alternative type of rent is selected in line 10u. If the amount is negative due to a utility reimbursement, enter the negative amount and credit the family.
10u, Type of rent selected: Income-based Flat MTW alternative gross income MTW Stepped rent MTW Tiered rent MTW alternative adjusted income Other MTW alternative rent |
11. Housing Choice Voucher: Project-Based Vouchers and Local, Non-Traditional Property-Based
Note: Complete if the family participates in the Project Based Voucher program (1c= PR) or Local, Non-Traditional Property-Based (1c = LP) and the type of action is New Admission (2a= 1), Annual Reexamination (2a= 2), Interim Reexamination (2a= 3), Portability Move-in (2a= 4), or Unit Change Only (2a= 7).
Line 11b: Indicate if the family is now moving into the unit.
Line 11d: Reserved.
Line 11e: Reserved.
.
Line 11f: Reserved.
Line 11g: Check the housing type that applies to the family’s housing unit.
Line 11h: The Section 8 unit owner’s legal name.
Line 11i: Tax identification number (TIN) or Social Security Number (SSN) of the legal unit owner.
Line 11j: HAP Contract ID number as assigned by the PBV HAP Contract Collection module in the Housing Information Portal (HIP). This contract ID number will be in the following format (CA024-2017-0000038 PHA Code – Effective Year of Contract – unique ID).
Line 11k: Total monthly rent amount paid to the unit owner under the lease, or other subsidized rent amount.
Line 11l: Indicate the amount ($) the PHA paid for a security deposit on behalf of the family. If the PHA did not provide a security deposit, enter $0
Line 11m: If the payment does not include all utilities, the monthly allowance amount for tenant supplied utilities that apply to the family occupied unit.
Line 11n: To get the unit’s total monthly rent amount, or gross rent, add the contract rent to owner (line 11k) and the utility allowance (line 11m).
Line 11q: The total tenant payment (TTP). Copy from 9j.
Line 11r: Total housing assistance payment (HAP), which is composed of the gross rent of unit (line 11n) minus total tenant payment (TTP) (line 11q).
Line 11s: The rent amount the family pays to the owner after deducting the total housing assistance payment (HAP) (line 11r) from the contract rent to owner (line 11k), or the total credit amount the family receives to pay utilities.
Line 11t: The amount of the housing assistance payment (HAP) to the unit owner. The lower amount of the contract rent to owner (line 11k) or total HAP (line 11r).
Line 11u: Using the options below, indicate the MTW specific alternative rent type the family’s rent is determined by if the family’s rent is not calculated using the standard rent calculation detailed on this form. Use “Other MTW alternative rent” if other types are not applicable, including for Local, Non-Traditional Property-Based program.
Line 11v: The total housing assistance payment (HAP) to the unit owner for a family if the PHA is utilizing an alternative rent, as indicated in 11u, or the family is participating in the Local, Non-Traditional Property-Based program.
Line 11w: Tenant rent to owner determined by the PHA for a family if the PHA is utilizing an alternative rent, as indicated in 11u, or the family is participating in the Local, Non-Traditional Property-Based program. If the amount is negative due to a utility reimbursement, enter the negative amount and credit the family.
Line 11aa: Amount of the normal total housing assistance payment. Subtract total tenant payment (TTP) (line 11q) from gross rent (line 11n).
Line 11ae: Total number of family members eligible for a rent subsidy based on the Noncitizens Rule.
Line 11af: Total number of family members in household.
Note: Include all family members, including ineligible noncitizen family members (3i= IN). Do not include live-in aides or foster children/adults.
Line 11ag: Percentage of family eligible for rent subsidy. Divide total number eligible (line 11ae) by total number in family (line 11af).
Line 11ah: Total prorated housing assistance payment (HAP). Multiply normal total HAP (line 11aa) by proration percentage (line 11ag).
Line 11ai: Total tenant payment (TTP) for the unit based on the proration calculation. Gross rent of unit (line 11n) minus prorated total housing assistance payment (HAP) (line 11ah).
Line 11aj: Monthly allowance amount for tenant supplied utilities if the payment does not include all utilities. Copy from line 11m.
Line 11ak: The rent amount the family pays to the owner after deducting the utility allowance (line 11aj) from the mixed family total tenant payment (TTP) (line 11ai), or the total credit amount the family receives to pay utilities.
Line 11an: The total prorated housing assistance payment (HAP) to the unit owner. Subtract the mixed family tenant rent (line 11ak) from the contract rent to owner (line 11k).
Note: If the mixed family tenant rent (line 11ak) is negative, enter the contract rent to owner (line 11k).
Line 11ap: Using the options below, indicate the MTW specific alternative rent type the family’s rent is determined by if the family’s rent is not calculated using the standard prorated rent calculation detailed on this form. Use “Other MTW alternative rent” if other types are not applicable, including for Local, Non-Traditional Property-Based program.
Line 11aq: The total prorated housing assistance payment (HAP) to the unit owner for a family if the PHA is utilizing an alternative rent, as indicated in 11ap, or the family is participating in the Local, Non-Traditional Property-Based program.
Line 11ar: Prorated tenant rent to owner determined by the PHA for a family if the PHA is utilizing an alternative rent, as indicated in 11ap, or the family is participating in the Local, Non-Traditional Property-Based program. If the amount is negative due to a utility reimbursement, enter the negative amount and credit the family.
Line 11as(1): Indicate whether the family received housing mobility-related services, provided or funded by the PHA, intended to help access lower-poverty, opportunity neighborhoods.
Line 11as(2): If the answer to 11as(1) is yes, enter the date the family first began receiving housing mobility-related services.
Line 11at: Total financial assistance provided by the PHA to a household when the household is leasing a new unit. Do not include any security deposit amount already entered in line 11l.
11u, MTW specific alternative rent type: MTW alternative gross income MTW Stepped rent MTW Tiered rent MTW alternative adjusted income Other MTW alternative rent |
11ap, MTW specific alternative rent type (prorated): MTW alternative gross income MTW Stepped rent MTW Tiered rent MTW alternative adjusted income Other MTW alternative rent |
12. Housing Choice Vouchers: Tenant Based Vouchers and Local, Non-Traditional Tenant-Based
Note: Complete if the family participates in the Tenant-Based Voucher program (1c = T) or Local, Non-Traditional Tenant-Based (1c = LN) and type of action is New Admission (2a= 1), Annual Reexamination (2a= 2), Interim Reexamination (2a= 3), Portability Move-in (2a= 4), or Unit Change Only (2a= 7).
Line 12a: Unit size (number of bedrooms) listed on the family’s Voucher.
Line 12b: Indicate if the family is now moving into the unit.
Line 12d: Indicate whether or not the household will move or has moved into the PHA’s jurisdiction under portability.
Line 12e: Monthly amount billed to the initial PHA for the family’s housing assistance payment (HAP) amount, on-going administrative fee, and any utility reimbursement to the family.
Note: Enter 0 if the family was absorbed by the receiving PHA.
Line 12f: The initial PHA’s 2-letter state code and 3-digit identification number.
Note: For help obtaining the PHA’s identification number, contact the appropriate HUD field office.
Line 12g: Check the housing type that applies to the family’s housing unit.
Line 12h: The unit owner’s legal name.
Line 12i: Tax identification number (TIN) or Social Security Number (SSN) of the legal unit owner.
Line 12j: Enter maximum monthly assistance payment for a family assisted in the Voucher program.
Line 12k: Total monthly rent payable to the unit owner under the lease for the contract unit.
Line 12l: Indicate whether the PHA is providing a higher payment standard to the family as a reasonable accommodation. This includes EPS requests approved by the PHA or by HUD.
Line 12m: If the payment does not include all utilities, the monthly allowance amount for tenant supplied utilities that apply to the family occupied unit.
Line 12n: Indicate the amount ($) the PHA paid for a security deposit on behalf of the family. If the PHA did not provide a security deposit, enter $0.
Line 12o: Indicate whether the PHA provided mobility-related services to the family.
Line 12p: Gross rent of unit or space rent. Add rent to owner (line 12k) to the utility allowance (line 12m).
Line 12q: Lower of Voucher payment standard for family (line 12j) or gross rent of unit (line 12p).
Line 12r: Total tenant payment (TTP). Copy from 9j.
Line 12s: Total housing assistance payment (HAP), which is composed of the lower of the payment standard for the family or gross rent (line 12q) minus total tenant payment (TTP) (line 12r).
Line 12t: Amount the family contributes toward rent and utilities. Subtract total housing assistance payment (HAP) (line 12s) from gross rent of unit (line 12p).
Line 12u: The amount of the housing assistance payment (HAP) to the unit owner. The lower of the rent to owner (line 12k) or total HAP (line 12s).
Line 12v: Rent amount the family pays to the owner after deducting the housing assistance payment (HAP) to owner (line 12u) from the rent to owner (line 12k).
Line 12w: The utility reimbursement to the family from the PHA. Subtract housing assistance payment (HAP) to owner (line 12u) from total HAP (line 12s), but do not exceed the utility allowance (line 12m).
Line 12x: Using the options below, indicate the MTW specific alternative rent type the family’s rent is determined by if the family’s rent is not calculated using the standard rent calculation detailed on this form. Use “Other MTW alternative rent” if other types are not applicable, including for Local, Non-Traditional Tenant-Based program.
Line 12y: The total housing assistance payment (HAP) to the unit owner for a family if the PHA is utilizing an alternative rent, as indicated in 12x, or the family is participating in the Local, Non-Traditional Tenant-Based program.
Line 12z: Tenant rent to owner determined by the PHA for a family if the PHA is utilizing an alternative rent, as indicated in 12x, or the family is participating in the Local, Non-Traditional Tenant-Based program. If the amount is negative due to a utility reimbursement, enter the negative amount and credit the family.
Line 12ab: The amount of the normal total housing assistance payment (HAP).
Line 12ac: Total number of family members eligible for rent subsidy based on the Noncitizens Rule.
Line 12ad: Total number of family members in household.
Note: Include all family members, including ineligible noncitizen family members (3i= IN). Do not include live-in aides or foster children/adults.
Line 12ae: Percentage of family eligible for rent subsidy. Divide total number eligible (line 12ac) by total number in the family (12ad).
Line 12af: Multiply total normal housing assistance payment (HAP) (line 12ab) by the proration percentage (line 12ae).
Line 12ag: The mixed family total family contribution based on the proration calculation. Take the gross rent of unit (line 12p) minus prorated total housing assistance payment (HAP) (line 12af).
Line 12ah: If the payment does not include all utilities, the monthly allowance amount for tenant supplied utilities that apply to the family occupied unit.
Line 12ai: The rent amount the family pays to the owner after subtracting the utility allowance (line 12ah) from the mixed family total family contribution (line 12ag); or the total credit amount the family receives to pay for utilities.
Line 12aj: The total prorated amount of the housing assistance payment (HAP) to the unit owner. Subtract the mixed family tenant rent to owner (line 12ai) from the rent to owner (line 12k).
Note: If the mixed family tenant rent to owner (line 12ai) is negative, enter the rent to owner (line 12k).
Line 12ak: Using the options below, indicate the MTW specific alternative rent type the family’s rent is determined by if the family’s rent is not calculated using the standard prorated rent calculation detailed on this form. Use “Other MTW alternative rent” if other types are not applicable, including for Local, Non-Traditional Tenant-Based program.
Line 12am: The total prorated housing assistance payment (HAP) to the unit owner for a family if the PHA is utilizing an alternative rent, as indicated in 12ak, or the family is participating in the Local, Non-Traditional Tenant-Based program.
Line 12an: Prorated tenant rent to owner determined by the PHA for a family if the PHA is utilizing an alternative rent, as indicated in 12ak, or the family is participating in the Local, Non-Traditional Tenant-Based program. If the amount is negative due to a utility reimbursement, enter the negative amount and credit the family.
Line 12ap: Total financial assistance provided by the PHA to a household when the household is leasing a new TBV unit. Include security deposit in total financial assistance if paid for a family.
Line 12aq: Total financial assistance provided by the PHA to the landlord when a household is leasing a new TBV unit.
12x, MTW specific alternative rent type: MTW alternative gross income MTW Stepped rent MTW Tiered rent MTW alternative adjusted income Other MTW alternative rent |
12kp, MTW specific alternative rent type (prorated): MTW alternative gross income MTW Stepped rent MTW Tiered rent MTW alternative adjusted income Other MTW alternative rent |
15. Homeownership Vouchers
Note: Complete if program type is Homeownership (line 1c = H) and type of action is New Admission (2a= 1), Annual Reexamination (2a= 2), Interim Reexamination (2a= 3), Portability Move-in (2a= 4), or Other Change of Unit (2a= 7).
Line 15a: Indicate if the family is now moving into the home.
Line 15b: Date of the initial housing quality standards (HQS) inspection.
Line 15c: Indicate whether or not the household will move or has moved into the PHA’s jurisdiction under portability.
Line 15d: Monthly amount billed to the initial PHA for the family’s housing assistance payment (HAP) amount, on-going administrative fee, and any utility reimbursement to the family.
Note: Enter 0 if the family was absorbed by the receiving PHA.
Line 15e: The initial PHA’s 2-letter state code and 3-digit identification number.
Note: For help obtaining the PHA’s identification number, contact the appropriate HUD field office.
Line 15f: 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 15g: The PHA’s utility allowance for the unit.
Line 15h: The amount of PHA’s allowance for the homeowner’s monthly routine maintenance costs.
Line 15i: The amount of the PHA’s allowance for the homeowner’s major home repairs and replacements.
Line 15j: If applicable, enter co-op occupancy charges or condominium association assessments.
Line 15k: The amount of principal and interest for debt associated with home improvements on the unit.
Line 15m: Calculation of tenant’s total cost of homeownership. Sum of 15f through 15k.
Line 15n: Enter the lower of the payment standard for the unit size as indicated on the family’s Voucher or the payment standard for the unit size that the family actually owns.
Line 15p: The lower of gross homeownership expense (line 15m) and the payment standard for the family (line 15n).
Line 15q: Total tenant payment (TTP). Copy from 9j.
Line 15r: The amount of monthly homeownership assistance payment (HAP). Subtract total tenant payment (TTP) (line 15q) from the lower of 15m and 15n (line 15p).
Note: If the TTP (line 15q) is larger, enter 0.
Line 15s: Total amount the family contributes toward homeownership. Subtract housing assistance payment (HAP) (line 15r) from gross homeownership expense (line 15m).
Line 15aa: The amount of the normal total housing assistance payment.
Line 15ab: Total number of family members eligible for homeownership subsidy based on the Noncitizens Rule.
Line 15ac: Total number of family members in the household.
Note: Include all family members, including ineligible noncitizen family members (3i= IN). Do not include live-in aides or foster children/adults.
Line 15ad: Percentage of family eligible for homeownership subsidy. Divide the total number eligible (line 15ab) by the total number in family (line 15ac).
Note: Do not include live-in aides or foster children and adults. Include ineligible noncitizen family members as part of the total family number.
Line 15ae: The total prorated amount of the homeownership assistance payment (HAP) to the homeowner. Multiply normal total HAP (line 15aa) by the proration percentage (line 15ad).
Line 15af: The mixed family total family contribution based on the proration calculation. Subtract the prorated housing assistance payment (HAP) (line 15ae) from the gross homeownership expense (line 15m).
17. Supportive Services Programs (SSP)/MTW Self-Sufficiency
Note: Complete this section if the family participates in a supportive services program (e.g., Family Self Sufficiency, Resident Opportunity and Self Sufficiency (ROSS) Program, Jobs Plus, or MTW self-sufficiency program.
Line 17a: Select the option below to indicate if the family participates in a supportive services program, an MTW self-sufficiency program, or both a supportive service program and MTW self-sufficiency.
Line 17b: Check one category to indicate the purpose of the addendum.
Line 17c: The effective date of the SSP action.
Line 17d: The PHA code associated with the PHA that provides the FSS services.
Note: For help obtaining the PHA’s identification number, contact the appropriate HUD field office.
Line 17e: Check one category to indicate the purpose of the MTW self-sufficiency Addendum.
Line 17f: The effective date of the MTW self-sufficiency action.
Line 17h(1): Select the option below to indicate the head of household’s current employment status. For FSS, use the FSS HoH even if different from the HoH for Rental Assistance purposes.
Line 17h(2): The date the head of household began their current job.
Line 17h(3): Select the option below to identify the head of household’s current employment benefits (for FSS, use FSS HoH). Check all that apply.
Line 17h(4): Enter the highest grade or the full years of formal schooling that the head of household (for FSS, use FSS HoH) completed (0-25).
Note: Years of schooling begin with first grade (do not count kindergarten or pre-school).
Line 17h(5): Select the option below to indicate whether or not the family receives assistance, such as food stamps, Medicaid, TANF assistance, or the earned income tax credit.
Line 17h(6): The number of children in the household who receive childcare services.
17a. Special Service Programs: Family Self-Sufficiency (FSS) ROSS Jobs Plus MTW Self-Sufficiency
17h(1). Employment status: Full-time (32 hours per week or more) Part-time Not employed
|
17h(3). Employment benefits: Health Retirement Account Other
17h(5) Assistance: TANF Income Assistance General Assistance Food Stamps/SNAP Medicaid/Children’s Health Insurance Program Earned Income Tax Credit Social Security Disability Insurance (SSDI) or Interim Disability Assistance (IDA) Supplemental Security Income (SSI) |
Line 17i(1): Indicate whether or not the PHA identified individual training and service needs of the family members participating in the program identified in 17a.
Line 17i(2): For every need identified, indicate whether or not these needs were met during participation in the SS program.
Line 17j(1): FSS enrollment report only. The effective date of the family’s FSS contract of participation; the date the family initially enrolled in the FSS program.
Line 17j(2): FSS progress reports after the first income re-certification after the effective date of the CoP only. The expiration date of the family's FSS contract of participation; the date the family is initially expected to exit the FSS program. The contract term is for a period of 5 years from the first income re-certification after the effective date of the CoP.
Line 17j(3): If applicable, the date to which the PHA has extended the family’s FSS contract of participation.
Line 17j(4): The number of family members in the household who have current Individual Training and Services Plans under the FSS contract of participation.
Line 17k(1): The current dollar amount credited to the family’s account.
Line 17k(2): The current dollar amount of the family’s FSS account based on the most recent report of account funds and activity.
Line 17k(3): Total dollar cumulative amount, if any, of all interim FSS escrow disbursements ever made to the family.
Line 17m(1): Indicate if the family fulfilled all of its obligations under the contract during the contract term.
Line 17m(2): Indicate if the family completed the contract and is moving to homeownership.
Line 17m(3): If not graduation in (17(m)(1), indicate from the options below why the family exited the program.
17m(3) Exit reason: Left voluntarily Portability move-out (but not Termination with Escrow Disbursment) FSS Contract expired but family did not fulfill obligations Asked to leave program Left because essential service was unavailable Termination with Escrow Disbursement |
Line 17n: The PHA code for the PHA that is managing the rental assistance for this FSS participant. May be different than 17d.
MTW Self-Sufficiency Program
Line 17p(1): MTW self-sufficiency 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 17p(2): MTW self-sufficiency progress. The expiration date of the family's contract of participation; the date the family is initially expected to exit the self-sufficiency program.
Line 17p(3): If applicable, the date to which the PHA has extended the family's MTW self-sufficiency contract of participation.
Line 17p(4): The number of family members in the household who have current Individual Training and Services Plans under the contract of participation.
Line 17q(1): The current dollar amount credited to the family’s account.
Line 17q(2): The current dollar amount of the family’s account based on the most recent report of account funds and activity.
Line 17q(3): Total dollar cumulative amount, if any, of all interim escrow disbursements ever made to the family.
Line 17r(1): Indicate if the family fulfilled all of its obligations under the contract during the contract term.
Line 17r(2): Indicate if the family completed the contract and is moving to homeownership.
Line 17r(3): Indicate why the family did not complete its MTW self-sufficiency contract.
17r(3) Exit reason: Left voluntarily Portability move-out (but not Termination with Escrow Disbursment) FSS Contract expired but family did not fulfill obligations Asked to leave program Left because essential service was unavailable Termination with Escrow Disbursement Rental Assistance ended but did not complete FSS Contract |
Line 17s(1): Indicate whether or not the PHA identified individual training and service needs of the family members.
Line 17s(2): For every need identified, indicate whether or not the program meets these needs.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Threet, Daniel K |
| File Modified | 0000-00-00 |
| File Created | 2023-10-17 |