HUD-50058 Family Report applies to Public Housing Choice V

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

U.S. Department of Housing and

Urban Development

Office of Public and Indian Housing

Family Report

Form HUD-50058, Family Report, applies to Public Housing, Housing Choice Voucher, and Section 8 Moderate Rehabilitation programs.

Additional instructions are contained in the Form HUD-50058 Instruction Booklet. Copies of the Instruction Booklet can be found on the HUD website at http://www.hud.gov/offices/pih/systems/pic/50058/pubs/http://www.hud.gov/sites/documents/50058i.pdf

Read this before you complete or respond to this form HUD-50058. If you are filling this out on behalf of a family, you must ensure that the family receives the Paperwork Reduction Act and Privacy Statement.

Public Reporting Burden: Public reporting burden for this collection of information is estimated to average 45 minutes per response in the first year and 25 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. Comments regarding the accuracy of this burden estimate and any suggestions for reducing this burden can be sent to the Reports Management Officer, QDAM, Department of Housing and Urban Development, 451 7th St SW, Room 4176, Washington, DC 20410-5000. When providing comments, please refer to OMB Approval No. 2577-0083. This agency may not collect this information, and you are not required to complete this Form, unless it displays a currently valid OMB control number.

Privacy Act Information. This collection is authorized by the U.S. Housing Act of 1937 (42 U. S. C. 1437 et seq.), Title VI of the

Civil Rights Act of 1964 (42 U. S. C. 2000d) and by the Fair Housing Act (42 U. S. C. 3601-19). Each affected agency must submit

information to assist HUD in managing and monitoring HUD assisted housing programs, to protect the Government’s interest,

and to verify the accuracy of the information received. 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, detect fraud, and (4) plan for future use of the housing inventory with emphasis on the housing needs of special groups. HUD discloses this information in a limited nature to perform these activities with HUD’s Office of Public and Indian Housing, with HUD’s Office of Inspector General, with the Social Security Administration, HHS, FEMA, the FCC, other federal agencies, and with other State & Local agencies, including Public Housing Agencies, consistent with HUD’s published Privacy Act systems of record. HUD may use this data for research purposes, such as modeling the effect of proposed rent reforms. Research may be conducted by research firms under contract to HUD. The information requested is required to obtain or retain benefits. Failure to provide SSN could result in denial of eligibility and/or termination of assistance or tenancy participants. HUD is authorized to collect this information under the Housing and Community Development Act of 1987 42 U.S.C.3543(a). You can find the IMS (Inventory Management System) system of records notice and other HUD’s Privacy Act systems of records notices at https://www.hud.gov/program_offices/officeofadministration/privacy_act/pia/fednotice/SORNs_LoB.

Purpose of this information collection:

• Analyze assisted housing programs;

• Determine the occupancy level of public housing and calculate the operating subsidy in accordance with 24 CFR 990;

• Permit PHAs to monitor their own reporting to identify favorable and unfavorable trends;

• Monitor PHAs and participants for compliance with program regulations and requirements;

• Monitor compliance with fair housing laws and other civil rights statutes;

• Fraud detection and prevention via rent/income monitoring;

• Housing inventory and development of program initiatives with emphasis on the housing of special needs groups; and

• Make available accurate demographic information depicting tenant characteristics to Congress and other interested parties.

Sensitive Information: The information on these forms is sensitive and is protected by the Privacy Act. Keep the forms locked and confidential.

Acronyms

FMR = Fair Market Rent FSS = Family Self-Sufficiency program HAP = Housing Assistance Payment HIP = Housing Information Portal HQS = Housing Quality Standards HUD = U.S. Department of Housing and Urban Development ISA = Individual Savings Account OMB = U.S. Office of Management and Budget PHA = Public Housing Agency PHRA = Public Housing Reform Act

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

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

Disabilities: A person with a disability is any individual who has a physical or mental impairment that substantially limits one or more major life activities; has a record of such an impairment; or is regarded as having such an impairment. A person with a disability can also include one or more of the following: (a) a disability as defined in Section 223 of the Social Security Act, (b) a physical, mental, or emotional impairment which is expected to be of long-continued and indefinite duration, substantially impedes his or her ability to live independently, and is of such a nature that such ability could be improved by more suitable housing conditions, or (c) a developmental disability as defined in Section 102 of the Developmental Disabilities Assistance and Bill of Rights Act. Note: Include persons who have the acquired immune deficiency syndrome (AIDS) or any condition that arises from the etiologic agent for AIDS.

Effective Date of Action: Date the reported action becomes effective. The effective date cannot be earlier than the date of admission to the program.

Head of household: The one adult member of the household, designated by the family or by PHA policy as the head of household, who is wholly or partly responsible for the rent payment.

Mixed Family: A family that contains some members that are eligible for assistance and some members that are ineligible for assistance. This family may be subject to prorated rent under the Noncitizens Rule.

Portability: Renting a dwelling unit with Housing Choice Voucher assistance outside the jurisdiction of the initial PHA.

Form Conventions:

1. All fields that require the entry of a date must include the 4-digit year. Enter the date in a standard format (i.e., "mm/dd/yyyy", "mm/yyyy"). Enter the year in its entirety.

2. "/" means "or" unless otherwise noted.

3. Monetary figures: enter only whole dollar amounts. Do not show cents, commas, or dollar signs.

4. Rounding: round each monetary amount up when a number is 0.50 or above; down when a number is 0.49 or below.

5. Calculation column is a scratch area where PHAs may perform manual calculations.

6. Leave blank any line(s) or item(s) that do not apply unless this Form instructs otherwise.

Head of household name:	Social Security Number:	Date Modified:
Family Report U.S. Department of Housing and Urban Development OMB Approval Number 2577-0083 Office of Public and Indian Housing

1. Agency

1a. Agency name		1a.
1b. PHA code		1b.
1c. Program		1c.
1d. Project Number		1d.
1e. Building Number		1e.
1f. Building Entrance Number		1f.
1g. Unit Number		1g.
1h. Unit Real Estate ID Number (see instructions)		1h.

2. Action

2a. Type of Action		2a.
2b. Effective date (mm/dd/yyyy) of action		2b.
2c. Correction? (Y or N)		2c.
2d. If correction: (check primary reason) [ ] Family correction of income [ ] Family correction (non-income) [ ] PHA correction of family income [ ] PHA correction (non-income)
2h. Date (mm/dd/yyyy) of admission to program		2h.
2i. Projected effective date (mm/dd/yyyy) of next reexamination		2i.
2j. Projected date (mm/dd/yyyy) of next flat rent annual update (Public Housing flat rent only)		2j.
2k. Supportive Service Program participation now or in the last year? (Y or N)		2k.
2m. Special program: (vouchers only)	2m.
2n. Other special programs: Number 01		2n.
2n. Other special programs: Number 02		2n.
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.
2v. End of Participation reason (only if 2a= 6/End Participation)	2v.
2w. Interim Reexamination reason (only if 2a= 3/Interim Reexamination)	2w.
2x. Type of voucher issuance (HCV only)	2x.
2y. Date participant vacated unit (HCV only)	2y.
2z. Special purpose	2z.
2aa. Special purpose	2aa.

3. Household

3a. Head of Household Member number 01	3b. Last name & Sr., Jr. etc.			3c. First name	3d. MI	3e. Date of birth	3f. Age on effective date of action
	3g. Gender	3h. Relation H	3i. Citizenship	3j. Disability	3k. Race		3m. Ethnicity
	3n. Social Security Number			3o. Special status code	3p. Alien Registration Number A-	3q. Meeting community service or self-sufficiency requirement? (PH only)
3a. Member number 02	3b. Last name & Sr., Jr. etc.			3c. First name	3d. MI	3e. Date of birth	3f. Age on effective date of action
	3g. Gender	3h. Relation	3i. Citizenship	3j. Disability	3k. Race		3m. Ethnicity
	3n. Social Security Number			3o. Special status code	3p. Alien Registration Number A-	3q. Meeting community service or self-sufficiency requirement? (PH only)
3a. Member number 03	3b. Last name & Sr., Jr. etc.			3c. First name	3d. MI	3e. Date of birth	3f. Age on effective date of action
	3g. Gender	3h. Relation	3i. Citizenship	3j. Disability	3k. Race		3m. Ethnicity
	3n. Social Security Number			3o. Special status code	3p. Alien Registration Number A-	3q. Meeting community service or self-sufficiency requirement? (PH only)
3a. Member number 04	3b. Last name & Sr., Jr. etc.			3c. First name	3d. MI	3e. Date of birth	3f. Age on effective date of action
	3g. Gender	3h. Relation	3i. Citizenship	3j. Disability	3k. Race		3m. Ethnicity
	3n. Social Security Number			3o. Special status code	3p. Alien Registration Number A-	3q. Meeting community service or self-sufficiency requirement? (PH only)
3a. Member number 05	3b. Last name & Sr., Jr. etc.			3c. First name	3d. MI	3e. Date of birth	3f. Age on effective date of action
	3g. Gender	3h. Relation	3i. Citizenship	3j. Disability	3k. Race		3m. Ethnicity
	3n. Social Security Number			3o. Special status code	3p. Alien Registration Number A-	3q. Meeting community service or self-sufficiency requirement? (PH only)
3a. Member number 06	3b. Last name & Sr., Jr. etc.			3c. First name	3d. MI	3e. Date of birth	3f. Age on effective date of action
	3g. Gender	3h. Relation	3i. Citizenship	3j. Disability	3k. Race		3m. Ethnicity
	3n. Social Security Number			3o. Special status code	3p. Alien Registration Number A-	3q. Meeting community service or self-sufficiency requirement? (PH only)
3a. Member number 07	3b. Last name & Sr., Jr. etc.			3c. First name	3d. MI	3e. Date of birth	3f. Age on effective date of action
	3g. Gender	3h. Relation	3i. Citizenship	3j. Disability	3k. Race		3m. Ethnicity
	3n. Social Security Number			3o. Special status code	3p. Alien Registration Number A-	3q. Meeting community service or self-sufficiency requirement? (PH only)
3t. Total number in household						3t.
3u. Family subsidy status under Noncitizens Rule						3u.
3v. Eligibility effective date (mm/dd/yyyy) if qualified for continuation of full assistance (3u=C)						3v.
3w. If new head of household, former head of household’s SSN						3w.

4. Background at Admission

4a. Date (mm/dd/yyyy) entered waiting list	4a.
4b. Date (mm/dd/yyyy) selected from waiting list	4b.
4c. ZIP code before admission	4c.
4d. Homeless at admission? (Y or N)	4d.
4e. Formerly homeless? (Y or N)	4e.
4f. Does family qualify for admission over the very low-income limit? (vouchers only) (Y or N)	4f.
4g. Continuously assisted under the 1937 Housing Act? (Y or N)	4g.
4h. Transitioning out of institutional setting? (Y or N)	4h.
4i. Is this a special admission (non-waiting list admission)? (Y or N)	4i.

5. Unit to be Occupied on Effective Date of Action

5a. Unit Address
Number and street					Apt.
City	Urbanization (Puerto Rico only)	State		ZIP code (+4)
5b. Is mailing address same as unit address? (Y or N) (if yes, skip to 5d)						5b.
5c. Family’s mailing address
Number and street					Apt.
City	Urbanization (Puerto Rico only)	State	ZIP code (+4)
5d. Number of bedrooms in unit						5d.
5e. PHA identified accessible unit (PBV only) Has the PHA identified this unit as an accessible unit? If yes, what type of accessibility features does the unit have?						5e(1).
						5e(2).
5f. Family requested accessibility features (Public Housing and PBV only) Has the family requested accessibility features? If yes, what type of accessibility features have they requested?						5f(1).
						5f(2).
5g. Has the family received requested accessibility features? (Public Housing and PBV) [ ] 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 inspection (Section 8 only, except Homeownership Vouchers)						5h.
5i. Date (mm/dd/yyyy) of last inspection (Section 8 only, except Homeownership Vouchers)						5i.
5j. Was the last passed inspection an alternative inspection? (Y or N)						5j.
5k. Year (yyyy) unit was built (Section 8 only)						5k.
5l Structure type (check only one) (Section 8 only) [ ] Single family detached [ ] Semi-detached [ ] Rowhouse/townhouse [ ] Low-rise [ ] High rise with elevator [ ] Manufactured home

6. Assets

6a. Family Member Name	No.	6b. Type of asset	6c. Is this asset included in net family assets?	6d. Cash value of asset	6e. Actual Income	6f. Imputed Income
				$	$	$
				$	$	$
				$	$	$
				$	$	$
				$	$	$
				$	$	$
				$	$	$
				$	$	$
6g, 6h, 6i. Total net family assets, total actual income, total imputed income				$ 6g.	$ 6h.	$ 6i.
6j. Passbook rate (written as decimal)						6j.
6k. Final asset income: 6h + 6i (see instruction booklet)						6k.

7. Income

7a. Family Member Name	No.	7b. Income Code	7c. Calculation (PHA use)	7d. Dollars per year	7e. Income exclusions	7f. Income after exclusions (7d minus 7e)
				$	$	$
				$	$	$
				$	$	$
				$	$	$
				$	$	$
				$	$	$
				$	$	$
				$	$	$
				$	$	$
				$	$	$
				$	$	$
				$	$	$
7g. Column total						$ 7g.
7h. Reserved
7i. Total annual income: 6k + 7g						7i.
Over-Income Status (Public Housing Only)
7j. What is the applicable over-income limit for families of this size?						$ 7j.
7k. Is the family’s annual income greater than the over-income limit? [ ] Y [ ] N						7k.
7l. If the family is over-income, note the start date of the 24 consecutive month grace period						7l.

8. Deductions and Allowances

8a. Total annual income: copy from 7i			$ 8a.
Permissive Deductions
8b. Family Member Name	No.	8c. Type of permissive deduction	8d. Amount
			$
			$
			$
			$
			$
			$
8e. Total permissive deductions (sum of column 8d)			$ 8e.
If head/spouse/co-head is under 62 and no family member is disabled, skip to 8l
8f. Medical/disability threshold: 8a X 0.10			$ 8f.
8g. Total annual unreimbursed disability assistance expense (if no disability expenses, skip to 8k)			$ 8g.
8h. Maximum disability allowance: If 8g minus 8f is positive or zero, put amount			$ 8h.
	If negative and head/spouse/co-head is under 62 and not disabled, put 0		$ 8h.
	If negative and head/spouse/co-head is elderly or disabled, copy from 8g		$ 8h.
8i. Earnings in 7d made possible by disability assistance expense			$ 8i.
8j. Allowable disability assistance expense: lower of 8h or 8i (if 8g is less than 8f and head/spouse/co-head elderly or disabled, copy from 8h)			$ 8j.
8k. Total annual unreimbursed health/medical expenses (if head/spouse/co-head under 62 and not disabled, put 0)			$ 8k.
8l. Family is eligible for medical or child care expense hardship or both?			8l.
8m. Total annual disability assistance and medical expense: 8j + 8k (if no disability expenses, copy from 8k)			$ 8m.
8n. Medical/disability assistance deduction:	If no disability assistance expenses or if 8g is less than 8f, put 8m minus 8f (if 8m minus 8f is negative, put zero)		$ 8n.
	If disability assistance expenses and 8g is greater than or equal to 8f, copy from 8m		$ 8n.
8p. Elderly/disability allowance			$ 8p.
8q. Number of dependents (people under 18, or with disability, or full-time student. Do not count head of household, spouse, co-head, foster child/adult, or live-in aide.)			8q.
8r. Allowance per dependent			$ 8r.
8s. Dependent allowance: 8q X 8r			$ 8s.
8t. Total annual unreimbursed child care costs			$ 8t.
8x. Total allowances: 8e + 8n + 8p + 8s + 8t			$ 8x.
8y. Adjusted annual income: 8a minus 8x (if 8x is larger, put 0)			$ 8y.

9. Total Tenant Payment (TTP)

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

10. Public Housing

10a. TTP: copy from 9j			$ 10a.
10b. Unit’s flat rent			$ 10b.
Income Based Rent Calculation (if prorated rent, skip to 10h)
10d. Income Based Rent (Lower of 10a or 10b if authorized to use ceiling rents; or if not, put 10a)			$ 10d.
10e. Utility allowance, if any			$ 10e.
10f. Tenant rent: 10d minus 10e		If positive or 0, put tenant rent	$ 10f.
		If negative, credit tenant	$ 10f.
Income Based Prorated Rent Calculation (if not prorated, skip to 10u)
10h. PHA-established flat rent			$ 10h.
10i. Family maximum subsidy: 10h minus 10a			$ 10i.
10j. Total number eligible			$ 10j.
10k. Total number in family			$ 10k.
10n. Eligible subsidy (10i ÷ 10k) X 10j			$ 10n.
10p. Mixed family TTP: 10h minus 10n			$ 10p.
10r. Utility allowance, if any			$ 10r.
10s. Mixed family tenant rent: 10p minus 10r		If positive or 0, put tenant rent	$ 10s.
		If negative, credit tenant	$ 10s.
Type of Rent
10u. Type of rent selected:	[ ] Income-based [ ] Flat

11. Section 8: Project-Based Vouchers

11b. Is family now moving to this unit? (Y or N)		11b.
11d. Reserved		11d.
11e. Reserved		11e.
11f. Reserved		11f.
11g. Housing type [ ] Group Home (prorate gross rent) [ ] SRO: 1 room occupied by 1 person
11h. Owner name		11h.
11i. Owner TIN/SSN		11i.
11j. HAP Contract ID Number		11j.
11k. Contract rent to owner (if unit has other subsidy, put subsidized rent)		$ 11k.
11l. Security deposit paid by the PHA on behalf of family, if any		$ 11l.
11m. Utility allowance, if any		$ 11m.
11n. Gross rent of unit: 11k + 11m		$ 11n.
11q. TTP: copy from 9j		$ 11q.
Rent Calculation (if prorated rent, skip to 11aa)
11r. Total HAP: 11n minus 11q. If 11q is larger, put 0		$ 11r.
11s. Tenant rent: 11k minus 11r	If positive or 0, put tenant rent	$ 11s.
	If negative, credit tenant	$ 11s.
11t. HAP to owner: lower of 11k or 11r		$ 11t.
Prorated Rent Calculation
11aa. Normal total HAP: 11n minus 11q		$ 11aa.
11ae. Total number eligible		11ae.
11af. Total number in family		11af.
11ag. Proration percentage: 11ae ÷ 11af		11ag.
11ah. Prorated total HAP: 11aa X 11ag		$ 11ah.
11ai. Mixed family TTP: 11n minus 11ah		$ 11ai.
11aj. Utility allowance: copy from 11m		$ 11aj.
11ak. Mixed family tenant rent: 11ai minus 11aj	If positive or 0, put tenant rent	$ 11ak.
	If negative, credit tenant	$ 11ak.
11an. Prorated HAP to owner: 11k minus 11ak (if 11ak is negative, put 11k)		$ 11an.
Additional Payments and Services (not HAP)
11ap. Mobility-related services (1) Did the family receive mobility-related services? (Y or N)	11ap(1).
(2) Date family began receiving mobility-related services	11ap(2).
11aq. Additional financial support for project-based voucher family	$ 11aq.

12. Housing Choice Vouchers: Tenant Based Vouchers

12a. Number of bedrooms on Voucher		12a.
12b. Is family now moving to this unit? (Y or N)		12b.
12d. Did family move into your PHA jurisdiction under portability? (Y or N) (if no, skip to 12g)		12d.
12e. Cost billed per month (put 0 if absorbed)		$ 12e.
12f. PHA code billed		12f.
12g. Housing type [ ] Group Home (prorate gross rent) [ ] Own manufactured home, lease space [ ] SRO: 1 room occupied by 1 person
12h. Owner name		12h.
12i Owner TIN/SSN		12i.
12j. Payment standard for the family		$ 12j.
12k. Rent to owner		$ 12k.
12l Is the family receiving a higher payment standard as a reasonable accommodation? (Y or N)		$ 12l.
12m. Utility allowance, if any		$ 12m.
12n. Security deposit paid by the PHA on behalf of the family, if any		$ 12n.
12o. Mobility-related services (1) Did the family receive mobility-related services? (Y or N) (2) Date family began receiving mobility-related services		12o(1).
		12o(2).
12p. Gross rent of unit: 12k + 12m (or Space Rent)		$ 12p.
12q. Lower of 12j or 12p		$ 12q.
12r. TTP: copy from 9j		$ 12r.
12s. Total HAP: 12q minus 12r		$ 12s.
Rent Calculation (if prorated rent, skip to 12ab)
12t. Total family share: 12p minus 12s		$ 12t.
12u. HAP to owner: lower of 12k or 12s		$ 12u.
12v. Tenant rent to owner: 12k minus 12u		$ 12v.
12w. Utility reimbursement to family: 12s minus 12u, but do not exceed 12m		$ 12w.
Prorated Rent Calculation
12ab. Normal total HAP: copy from 12s, but do not exceed 12p		$ 12ab.
12ac. Total number eligible		12ac.
12ad. Total number in family		12ad.
12ae. Proration percentage: 12ac ÷ 12ad		12ae.
12af. Prorated total HAP: 12ab X 12ae		$ 12af.
12ag. Mixed family total family contribution: 12p minus 12af		$ 12ag.
12ah. Utility allowance: copy from 12m		$ 12ah.
12ai. Mixed family tenant rent to owner: 12ag minus 12ah	If positive or 0, put tenant rent	$ 12ai.
	If negative, credit tenant	$ 12ai.
12aj. Prorated HAP to owner: 12k minus 12ai. If 12ai is negative, put 12k		$ 12aj.
Additional Payments (not HAP)
12ap. Additional financial support for tenant-based voucher family		$ 12ap.
12aq. Financial incentive for property owner		$ 12aq.

13. Section 8: Moderate Rehabilitation (Mod Rehab)

13a. HAP contract number		13a.
13b. Mod Rehab SRO Program for homeless? (Y or N)		13b.
13c. Mod Rehab SRO unit (not homeless program)? (Y or N)		13c.
13d. Owner name		13d.
13e. Owner TIN/SSN		13e.
13f. Current base rent		$ 13f.
13g. Rehabilitation debt service		$ 13g.
13h. Contract rent to owner: 13f + 13g		$ 13h.
13i. Utility allowance, if any		$ 13i.
13j. TTP: copy from 9j		$ 13j.
Rent Calculation (if prorated rent, skip to 13p)
13k. Tenant rent: 13j minus 13i (if 13j is greater than 13h + 13i, put 13h)	If positive or 0, put tenant rent	$ 13k.
	If negative, credit tenant	$ 13k.
13m. HAP to owner: 13h minus 13k (if 13k is negative, put 13h)		$ 13m.
Prorated Rent Calculation
13p. Gross rent: 13h + 13i		$ 13p.
13q. Normal total HAP: 13p minus 13j		13q.
13r. Total number eligible		13r.
13s. Total number in family		13s.
13t. Proration percentage: 13r ÷ 13s		13t.
13u. Prorated total HAP: 13q X 13t		$ 13u.
13v. Mixed family TTP: 13p minus 13u		$ 13v.
13w. Utility allowance: copy from 13i		$ 13w.
13x. Mixed family tenant rent: 13v minus 13w	If positive or 0, put tenant rent	$ 13x.
	If negative, credit tenant	$ 13x.
13z. Prorated HAP to owner: 13h minus 13x (if 13x is negative, put 13h)		$ 13z.

15. Homeownership Vouchers

15a. Is family now moving to this home? (Y or N)	15a.
15b. Date (mm/dd/yyyy) of initial HQS inspection	15b.
15c. Did family move into your PHA jurisdiction under portability? (Y or N) (if no, skip to 15f)	15c.
15d. Cost billed per month (put 0 if absorbed)	$ 15d.
15e. PHA code billed	15e.
15f. Monthly homeownership payment (PITI & MIP if applicable)	$ 15f.
15g. Utility allowance	$ 15g.
15h. Monthly maintenance allowance	$ 15h.
15i. Monthly major repair/replacement allowance	$ 15i.
15j. Monthly Co-op/Condominium assessments	$ 15j.
15k. Monthly principal and interest on debt for improvements, if any	$ 15k.
15m. Gross homeownership expense: 15f + 15g + 15h + 15i + 15j + 15k	$ 15m.
15n. Payment standard for family	$ 15n.
15p. Lower of 15m and 15n	$ 15p.
15q. TTP: copy from 9j	$ 15q.
15r. HAP: 15p minus 15q (if 15q is larger, put 0)	$ 15r.
Subsidy Calculation (if prorated, skip to 15aa)
15s. Total family share: 15m minus 15r	$ 15s.
Prorated Subsidy Calculation
15aa. Normal total HAP: copy from 15r	$ 15aa.
15ab. Total number eligible	15ab.
15ac. Total number in family	15ac.
15ad. Proration percentage: 15ab ÷ 15ac	15ad.
15ae. Prorated HAP: 15aa X 15ad	$ 15ae.
15af. Mixed family total family share: 15m minus 15ae	$ 15af.

17. Supportive Services Programs (SSP)

17a. Participate in special programs?			17a.
17b. SSP report category: (check no more than one) [ ] Enrollment [ ] Progress [ ] Exit
17c. Effective date (mm/dd/yyyy) of SSP action
17d. PHA code of PHA administering FSS contract (FSS only)
17e. PHA code of PHA that is managing the rental assistance for this FSS participant (May be different from 17d) (FSS only)
17h. General information (HoH = FSS HoH for FSS participants)
Current employment status of head of household. Check the box to indicate the head of household’s employment status at the time addendum completed.			17h(1).
Date (mm/dd/yyyy) current employment began
Benefits in current employment: (check all that apply)			17h(3).
Years of school completed by the head of household. Enter the highest grade of education or years of formal schooling the head of household completed at the time Addendum is submitted. (0-25)
Assistance currently received by the family: (check all that apply)			17h(5).
Number of children receiving childcare services
17i. Family services table
	(1) Need (Y or N)	(2) Need Met Through Participation in Program (Y or N)
Education/Training
GED/high school
Post secondary
ESL
Employment Supports
Job search/job placement
Job retention
Vocational/Job training
Job Readiness
Transportation
Child care
Personal Welfare
Health services
Alcohol and substance use prevention and treatment services
Mental health
Dental
Health insurance
Financial Empowerment
Homeownership and Housing counseling
Connected to Banking Services at a Mainstream Financial Institution (Checking or Savings)
Financial Empowerment/coaching
Digital Inclusion Activities
Elderly/Persons with Disabilities
Other
17j. FSS Contract Information (FSS Only)
Start date (mm/yyyy) of contract of participation (FSS enrollment report only)		17j(1).
Initial end date (mm/yyyy) of contract of participation (to be entered on the first Progress report after the effective date of the CoP)		17j(2).
Contract date extended to (mm/yyyy) (if applicable)		17j(3).
Number of family members with Individual Training and Services Plan		17j(4).
17k. FSS escrow account information (FSS Only)
Current FSS account monthly credit		$ 17k(1).
Current FSS escrow account balance		$ 17k(2).
FSS account amount disbursed to the family (cumulative as of end of reporting period)		$ 17k(3).
17m. FSS exit information (FSS Exit Report only)
Did family complete contract of participation? (Y or N)
If (1) is Yes, did family move to homeownership? (Y or N)
If (1) is No, primary reason for exit (choose one):		17m(3).

Previous editions are obsolete

form HUD-50058 (XX/XXXX)