HUD-50058 MTW Family Report applies to Moving to Work Public Housi

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

U.S. Department of Housing and

Urban Development

Office of Public and Indian Housing

MTW Family Report

Form HUD­50058 MTW, Family Report, applies to Moving to Work Public Housing and Section 8.

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 40 minutes per response in the first year and 20 minutes per response in subsequent years. This estimate includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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 additional and more detailed definitions of fields 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

• 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.

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

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

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

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

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

MTW Family Report U.S. Department of Housing and Urban Development OMB Approval Number 2577-0083

Office of Public and Indian Housing Expires xx/xx/20xx

1. MTW Agency

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

2a. Type of Action	2a.
2b. Effective date (mm/dd/yyyy) of action	2b.
2c. Correction? (Y or N)	2c.
2d. If correction: (check primary reason) [ ] Family correction of income [ ] Family correction (non-income) [ ] PHA correction of family income [ ] PHA correction (non-income)
2h. Date (mm/dd/yyyy) of admission to program	2h.
2i. Projected effective date (mm/dd/yyyy) of next reexamination	2i.
2k. Supportive Service Program participation now or in the last year? (Y or N – See Section 23) (programs other than MTW self-sufficiency programs)	2k.
2n. Use if instructed by HUD	2n.
2p. Other special programs	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.
2v. MTW self-sufficiency program participation now or in last year? (Y or N)	2v.
2w. End of Participation reason (only if 2a = End Participation)	2w.
2x. Interim Reexamination reason (only if 2a = Interim Reexamination)	2x.
2y. Type of voucher issuance (HCV only)	2y.
2z. Date participant vacated unit (HCV only)	2z.
2aa. Special purpose	2aa.
2ab. Special purpose	2ab.

3. MTW Household

3a. Head of Household Member number 01	3b. Last name & Sr., Jr. etc.			3c. First name	3d. MI	3e. Date of birth		3f. Age on effective date of action
	3g. 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)
	3r. Total years of school (0-25)
3a. Member number 02	3b. Last name & Sr., Jr. etc.			3c. First name	3d. MI	3e. Date of birth		3f. Age on effective date of action
	3g. 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)
	3r. Total years of school (0-25)
3a. Member number 03	3b. Last name & Sr., Jr. etc.			3c. First name	3d. MI	3e. Date of birth		3f. Age on effective date of action
	3g. 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)
	3r. Total years of school (0-25)
3a. Member number 04	3b. Last name & Sr., Jr. etc.			3c. First name	3d. MI	3e. Date of birth		3f. Age on effective date of action
	3g. 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)
	3r. Total years of school (0-25)
3a. Member number 05	3b. Last name & Sr., Jr. etc.			3c. First name	3d. MI	3e. Date of birth		3f. Age on effective date of action
	3g. 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)
	3r. Total years of school (0-25)
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)
	3r. Total years of school (0-25)
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)
	3r. Total years of school (0-25)
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. MTW Family 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. MTW 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 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 inspection (Tenant-Based or Project-Based Assistance only)					5h.
5i. Date (mm/dd/yyyy) of last inspection (Tenant-Based or Project-Based Assistance only)					5i.
5j. Was the last passed inspection an alternative inspection? (Y or N)					5j.
5k. Year (yyyy) unit was built (Tenant-Based or Project-Based Assistance only)					5k.
5l. Structure type (check only one) (Tenant-Based or Project-Based Assistance only) [ ] Single family detached [ ] Semi-detached [ ] Rowhouse/townhouse [ ] Low-rise [ ] High rise with elevator [ ] Manufactured home

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

18. MTW Asset Income

18a. Family Member Name	No.	18b. Type of Asset	18c. Is this asset included in net family assets?	18d. Cash value of asset	18e. Actual Income	18f. Imputed Income
				$	$	$
				$	$	$
				$	$	$
				$	$	$
				$	$	$
				$	$	$
				$	$	$
				$	$	$
18g, 18h, 18i. Total net family assets, total actual income, total imputed income				$ 18g.	$ 18h.	$ 18i.
18j. Passbook rate (written as decimal)						$ 18j.
18k. Final asset income: 18h + 18i (see instructions)						$ 18k.

19. MTW Income

19a. Family Member Name	No.	19b. Income Code	19c. Calculation (PHA use)	19d. Dollars per year	19e. Income exclusions	19f. Income after exclusions (19d minus 19e)
				$	$	$
				$	$	$
				$	$	$
				$	$	$
				$	$	$
				$	$	$
				$	$	$
				$	$	$
				$	$	$
				$	$	$
				$	$	$
				$	$	$
19g., 19h. Column totals				$ 19g.		$ 19h.
19i. Total annual income: 18k + 19h						$ 19i.
19j. Deductions						$ 19j.
19k. Adjusted annual income: 19i minus 19j						$ 19k.
Over-Income Status (Public Housing Only)
19l. What is the applicable over-income limit for families of this size?						$ 19l.
19m. Is the family’s annual income greater than the over-income limit? (Y or N)						19m.
19n. If the family is over-income, note the start date of the 24 consecutive month grace period						19n.

20. MTW Public Housing

20a. Type of rent selected: [ ] Income-based [ ] Flat	20a.
20b. Tenant rent	$ 20b.
20c. Mixed family tenant rent	$ 20c.
20d. Utility allowance/estimate	$ 20d.
20e. Is this a ceiling rent? (Y or N)	20e.
20f. Reserved	20f.

21. MTW Tenant-Based or Project-Based Voucher

21a. Indicate if flat subsidy or income-based subsidy	[ ] Income-based [ ] Flat
21b. Number of bedrooms on voucher equivalent		21b.
21c. Is family now moving to this unit? (Y or N)		21c.
21d. Did family move into your PHA jurisdiction under portability? (Y or N) (if no, skip to 21g)		21d.
21e. Cost billed per month (put 0 if absorbed)		$ 21e.
21f. PHA code billed		21f.
21g. Owner name		21g.
21h. Owner TIN/SSN		21h.
21i. Rent to owner		21i.
21j. Utility allowance/estimate		$ 21j.
21k. Gross rent of unit: 21i + 21j (or Space Rent)		$ 21k.
21m. Flat subsidy amount, if any		$ 21m.
21n. Tenant rent to owner		$ 21n.
21p. Mixed family tenant rent to owner		$ 21p.
21q. Is this a ceiling rent? (Y or N)		21q.
21r. Total HAP		21r.
21s. HAP Contract ID Number (Project-Based Voucher only)		21s.
21t. Is the family receiving a higher payment standard as a reasonable accommodation? (Tenant-Based Voucher only) (Y or N)		21t.
21u. Security deposit paid by the PHA on behalf of the family, if any		21u.
21v. Mobility-related services (1) Did the family receive mobility-related services? (Y or N) (2) Date family began receiving mobility-related services		21v(1).
		21v(2).
21w. Additional financial support for family		21w.
21x. Financial incentive for property owner (Tenant-Based Voucher only)		21x.

22. MTW Homeownership Voucher

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

23. Supportive Services Programs (SSP)/MTW Self-Sufficiency

23a. Participate in special programs?
23b. SSP Report category (check no more than one) [ ] Enrollment [ ] Progress [ ] Exit
23c. SSP Effective date (mm/dd/yyyy) of action				23c.
23d. PHA code of PHA administering FSS contract (FSS only)				23d.
23e: MTW self-sufficiency report category: (check no more than one) [ ] Enrollment [ ] Progress [ ] Exit
23f: MTW self-sufficiency effective date (mm/dd/yyyy) of action				23f.
23h. General information (HoH = FSS HoH for FSS participants)
(1) Current employment status of head of household. Indicate the head of household’s employment status at the time addendum completed.
(2) Date (mm/dd/yyyy) current employment began				23h(2).
(3) Benefits in current employment: (check all that apply) [ ] Health [ ] Retirement account [ ] Other
(4) Reserved.				23h(4).
(5) Assistance received by the family: (select all that apply)
(6) Number of children receiving childcare services				23h(6).
23i. Family services table (for MTW self-sufficiency go to 23r)
	(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 Homeownership counseling
Connected to Banking Services at a Mainstream Financial Institution (Checking or Savings)
Financial Empowerment/coaching
Digital Inclusion Activities
Elderly/Persons with Disabilities
Other
Family Self-Sufficiency Program (if MTW self-sufficiency program, skip to 17n)
23j. FSS Contract Information (FSS only)
Initial start date (mm/yyyy) of contract of participation (FSS enrollment report only)				23j(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)				23j(2).
Contract date extended to (mm/yyyy) (if applicable)				23j(3).
Number of family members with Individual Training and Services Plan				23j(4).
23k. Escrow account information (FSS only)
Current account monthly credit				$ 23k(1).
Current account balance				23k(2).
Account amount disbursed to the family (cumulative as of end of reporting period)				23k(3).
23m. FSS exit information (FSS Exit Report only)
Did family complete contract of participation? (Y or N)				23m(1).
If (1) is Yes, did family move to homeownership? (Y or N)				23m(2).
If (1) is No, reason for exit (choose one)
23n. PHA code of PHA that is manging the rental assistance for this FSS participant (May be different from 23d) (FSS only)			23n.

MTW Self-Sufficiency Program

23p. MTW self-sufficiency Contract Information
Initial start date (mm/yyyy) of contract of participation			23n(1).
Initial end date (mm/yyyy) of contract of participation			23n(2).
Contract date extended to (mm/yyyy) (if applicable)			23n(3).
Number of family members with Individual Training and Services Plan			23n(4).
23q. Escrow account information
Current account monthly credit			$ 23p(1).
Current account balance			23p(2).
Account amount disbursed to the family (cumulative as of end of reporting period)			23p(3).
23r. Exit information (complete only for exit report)
Did family complete MTW self-sufficiency program? (Y or N)			23m(1).
If (1) is Yes, did family move to homeownership? (Y or N)			23m(2).
If (1) is No, reason for exit (choose one)
23s. MTW self-sufficiency family services table (for FSS go to 23i)
	(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 Homeownership counseling
Connected to Banking Services at a Mainstream Financial Institution (Checking or Savings)
Financial Empowerment/coaching
Digital Inclusion Activities
Elderly/Persons with Disabilities
Other

Previous editions are obsolete

form HUD-50058 MTW (04/20xx)