New HUD Form Tribal HUD VASH Family Report

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Overview

Form
Definitions

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Sheet 1: Form

Public reporting burden for this collection of information is estimated to average 90 minutes per response. This estimate includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This agency may not collect this information, and you are not required to complete this Form, unless it displays a currently valid OMB control number.

Privacy Act Information. This collection is authorized by the U. S. Housing Act of 1937 (42 U. S. C. 1437 et seq.), Title VI of the Civil Rights Act of 1964 (42 U. S. C. 2000d) 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. The information requested is required to obtain or retain benefits. This collection is mandatory. The information requested is required to obtain and retain benefits. Failure to provide SSN could result in denial of eligibility and/or termination of assistance or tenancy participants. HUD is authorized to collect this information under the Housing and Community Development Act of 1987 42 U.S.C.3543 (a). Sensitive Information: The information on these forms is sensitive and is protected by the Privacy Act. Keep the forms locked and confidential.

Eligible Veteran Name (Last, First, Mi):

Social Security Number:

Date Modified (mm/dd/yyyy):

Tribal HUD VASH Grantee Information

Current Federal Fiscal Year

Start:

End:

Tribe/TDHE:

TDHE Code:

Program:

Action

Type of Action:

Effective Date of Action:

Correction?

Reason for Correction:

Date of Admission to Program:

Date of Next Reexamination:

Effective Date of Reexamination:

Eligible Veteran Name (Last, First, Mi):

Social Security Number:

Date Modified (mm/dd/yyyy):

Household

Eligible Veteran- Member Number 01

Name (Last, First, MI):

Date of Birth:

Social Security#:

Tribal Member:

Veteran:

Yes

Race:

Ethnicity:

Sex:

Relation:

Disability:

Age on Effective Date of Action:

Member Number 02

Name (Last, First, MI):

Date of Birth:

Social Security#:

Tribal Member:

Veteran:

Race:

Ethnicity:

Sex:

Relation:

Disability:

Age on Effective Date of Action:

Member Number 03

Name (Last, First, MI):

Date of Birth:

Social Security#:

Tribal Member:

Veteran:

Race:

Ethnicity:

Sex:

Relation:

Disability:

Age on Effective Date of Action:

Member Number 04

Name (Last, First, MI):

Date of Birth:

Social Security#:

Tribal Member:

Veteran:

Race:

Ethnicity:

Sex:

Relation:

Disability:

Age on Effective Date of Action:

Member Number 05

Name (Last, First, MI):

Date of Birth:

Social Security#:

Tribal Member:

Veteran:

Race:

Ethnicity:

Sex:

Relation:

Disability:

Age on Effective Date of Action:

Member Number 06

Name (Last, First, MI):

Date of Birth:

Social Security#:

Tribal Member:

Veteran:

Race:

Ethnicity:

Sex:

Relation:

Disability:

Age on Effective Date of Action:

Member Number 07

Name (Last, First, MI):

Date of Birth:

Social Security#:

Tribal Member:

Veteran:

Race:

Ethnicity:

Sex:

Relation:

Disability:

Age on Effective Date of Action:

Eligible Veteran Name (Last, First, Mi):

Social Security Number:

Date Modified (mm/dd/yyyy):

Member Number 08

Name (Last, First, MI):

Date of Birth:

Social Security#:

Tribal Member:

Veteran:

Race:

Ethnicity:

Sex:

Relation:

Disability:

Age on Effective Date of Action:

Member Number 09

Name (Last, First, MI):

Date of Birth:

Social Security#:

Tribal Member:

Veteran:

Race:

Ethnicity:

Sex:

Relation:

Disability:

Age on Effective Date of Action:

Total Number in Household:

Former Head of Household's SSN:

Bedrooms for Household:

Background at Admission

Zip Code before Admission:

Homeless/At Risk of Homelessness at Admission:

Unit to be Occupied on Action Effective Date

Unit Address (Number and Street):

Apartment #:

City:

State:

Zip Code Plus 4:

County:

Mailing Address if Different from Unit (Number and Street):

Apartment #:

City:

State:

Zip Code Plus 4:

Bedrooms:

Structure Type:

Lease Start Date:

Lease End Date:

Bedroom Difference Justification:

Type of Property:

Total Tenant Payment (TTP)

Total Monthly TTP:

Eligible Veteran Name (Last, First, Mi):

Social Security Number:

Date Modified (mm/dd/yyyy):

Project Based Assistance

Number Bedrooms in Unit:

Owner Name:

Owner TIN/SSN:

Contract Rent:

Utility Allowance:

Gross Rent:

TTP:

Contributing Funds:

FMR:

110% of FMR:

Monthly RAP:

Total RAP to Owner:

Is Family Moving In?

-

HUD Approved to

Justification:

Exceed 110% FMR:

Tenant Based Assistance

Bedrooms on Voucher:

Owner Name:

Owner TIN/SSN:

Contract Rent:

Utility Allowance:

Gross Rent:

TTP:

Contributing Funds:

FMR:

110% of FMR:

Monthly RAP:

Total RAP to Owner:

Is Family Moving In?

-

HUD Approved to

Justification:

Exceed 110% FMR:

I certify that the Tribal HUD-VASH data collected in this document is accurate to the best of my knowledge and ability to prove. It reflects activities actually planned or accomplished during the program year. WARNING: Anyone who knowingly submits a false claim or makes a false statement is subject to criminal and/or civil penalties, including confinement for up to 5 years, fines, and civil and administrative penalties (18U.S.C. §§287,1001,1010,1012,1014; 31U.S.C. §3729,3802). In addition, any person who knowingly and materially violates any required disclosure of information, including intentional disclosure, is subject to a civil money penalty not to exceed $10,000 for each violation.

Signature:

Printed Name:

Date:

X

X

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Sheet 2: Definitions

Tribal HUD VASH Family Report
INSTRUCTIONS and DEFINITIONS
ELIGIBLE VETERAN
Name	Enter the Eligible Veteran's Last Name, First Name, Middle Initial.
Social Security #	Enter the Eligible Veteran's Social Security Number.
Date Modified	Enter the date the Tribal/TDHE representative fills out the form or modifies any form page.
TRIBAL HUD VASH GRANTEE INFORMATION
Current Federal Fiscal Year	Input start date beginning 10/1/YYYY and End Date 9/30/YYYY. For example, for the FY2023 Federal Fiscal Year the start date would be 10/1/2022 and End date 9/30/2023.
Tribe/TDHE	Name of the Tribe/TDHE that completes the family's Form
TDHE Code	Five-character code composed of the 2-letter postal state code and 3-digit number. For help obtaining the Tribe/TDHEs identification number, contact the Tribe/TDHE assigned Grants Management Specialist in the area ONAP.
Program	Select from the drop down
Tribal HUD VASH Project Based	This type of rental housing assistance is tied to a specific housing unit or units in a project developed for a specific population. The housing assistance stays with the unit or units and any household living in the unit must meet program requirements. If the household moves out of the subsidized unit, the household no longer receives rental housing assistance
Tribal HUD VASH Tenant Based	This type of rental housing assistance is not tied to a specific unit or development, but can be used in any qualifying open-market unit. The eligible applicant selects and rents a unit (whether private or TDHE-owned) that meets program requirements, and the tribe or TDHE makes rent subsidy payments on behalf of the household. The assistance stays with the household; if the household moves to a different unit that meets program qualifications, the tribe or TDHE makes rental payments to the owner of the new unit on the household’s behalf.
ACTION
Type of Action	Select the appropriate action from the drop down
New Admission	Eligible Veteran is a new admission to program or changes programs.
Annual Reexamination	The regularly scheduled annual reexamination of family income and circumstances
Interim Reexamination	The reexamination of family income and circumstances, other than at the regularly scheduled annual reexamination. An interim reexamination occurs at the request of the tenant as a result of a change in income status, addition or loss of a family member, or other circumstance that requires tenant rent adjustment.
End of Participation	Eligible Veteran and all family members discontinue participation in the Tenant Based or Project Based program. Report an End Participation if the family moves from one program to another.
Historic Adjustment	To capture information for households who do not have a New Admission recorded but require an action other than a new admission, annual reexamination or interim reexamination. Historical Adjustment will serve as the baseline action for the household.
Effective Date of Action	Date the reported action becomes effective. The effective date cannot be earlier than the date of admission to the program
Correction	Select from the drop down
Reason for Correction	Indicate the primary reason for the correction record. Requires Tribe/TDHE to indicate the reason for a correction.
Date Eligible Veteran Admitted to Program	Date the Tribe/TDHE initially admitted the family into the Project Based or Tenant Based program reported in Tribal VASH Grantee Information section. HUD uses this date to determine how long families participate in specific housing programs.
Date of Next Reexamination	Scheduled date for the next reexamination
Effective Date of Reexamination	The projected effective date of reexamination.
HOUSEHOLD
NOTE:	Complete for each household member. The first family member (member number 01) must be the head of household and Eligible Veteran. 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
Household Member Name	Include Last Name, Suffix (jr., II, III), First Name, Middle Initial (Eligible Veteran Name will auto populate for Household member 01)
Date of Birth	Date of Birth of Identified Member
Social Security #	Input Social Security # for Identified Member. Enter CDIB# if household member does not have a Social Security Number. (Eligible Veteran SSN will auto populate for member 01)
Tribal Member	Select from the drop down
Veteran	Select from the drop down. (Eligible Veteran Member 01 will auto populate)
Race	Choose from drop down- White, Black/African American, American Indian/Alaskan Native, Asian, Native Hawaiian/Other Pacific Islander.
Ethnicity	Select from drop down- Hispanic or Latino, Not Hispanic or Latino
Sex	Indicate the gender of each household member. Select "Other" when the applicant identifies as a gender other than Male or Female (M= Male, F= Female, Other).
Relation	Select the code at bottom of the page that best categorizes the relation or role of each household member. The veteran should be entered as the Head of household. All other relationships should identify household members relationship to the veteran.
Self	Eligible Veteran and Head of Household
Spouse	The marriage partner of the Eligible Veteran and head of household.
Co-head of Household	Household member who is equally responsible for the lease with the head of household. Indicate either a spouse or a co-head, but not both. A co-head never qualifies as a dependent. However, a co-head may be under 18 years old if declared an “emancipated minor”, as many states will allow an emancipated minor to sign a lease.
Foster Child/Adult	Foster child – A member of the household who is under 18 years of age or a member who is a full-time student, 18 years or older, and who is under the parental control and responsibility of someone other than his or her mother or father. Foster adult – A member of the household (usually a person with a disability, unrelated to the tenant family, who is unable to live alone) who is 18 years of age or older and for whom the family provides necessary shelter, care and protection
Other Youth under 18	Member of the household (regardless of disability status), who is under 18 years of age on the effective date of action, and is not a foster child
Full Time Student 18+	Member of the household, other than the Head, spouse or cohead, or foster child or adult, 18 years of age or older on the effective date of action (line 2b) who carries a subject load considered full-time for students under the standards and practices of the educational institution attended. An educational institution includes a vocational school with a diploma or certificate program, as well as a degree-granting institution.
Live-in Aide	A person who lives with an elderly or disabled person(s) and who: is determined to be essential to the care and well-being of the person(s); is not obligated to support the person(s); would not be living in the unit except to provide necessary supportive services
Other Adult	A member of the household (excludes foster adults), other than the head or spouse or co-head, who is 18 years of age or older on the effective date of action , regardless of disability status
Disability	Select from the drop down
Age on Effective Date of Action	Will auto calculate based on date of action minus date of birth of identified household member.
Total Number in Household	Will auto calculate based on the number of household member sections completed
Bedrooms for Household	Insert number of required bedrooms based on composition of household. Bedroom size must be determined based the number of family members living in the household, not on the number of bedrooms in the unit to be rented. Guidelines for determining unit size are one bedroom for each two persons within the household, except a. Persons of the opposite sex (other than spouses, and children under age 5) are not required to share a bedroom; b. Persons of different generations are not required to share a bedroom; c. Live-in aides must be allocated a separate bedroom. No additional bedrooms will be provided for the live-in aide’s family; and d. Single person families must be allocated zero or one bedroom. Therefore, in situations where the available housing has more bedrooms than necessary for the family size and composition, the rental assistance payment must be limited to the number of bedrooms based on the guidelines listed above. If a recipient chooses to ‘‘over house’’ a Veteran family by placing the family in a larger unit than the family requires under the above guidelines, the maximum amount of Tribal HUD–VASH funds that can be used to house the Veteran family is the rent for a unit sized in accordance with the guidelines, and in accordance with Section VI., subsection H of this Notice. Any additional rental costs due to over housing cannot be funded with Tribal HUD–VASH or regular IHBG funds, but can be funded by other resources. In addition, Tribes/TDHEs may want to consider shared housing arrangements in situations where appropriate-sized housing is limited, but where individual veterans could have a separate bedroom and share common areas.
Former Head of Household SSN#	If there is a change in Head of Household, input former head of household's SSN
BACKGROUND AT ADMISSION
ZIP Code before Admission	The 5-digit ZIP code where the family lived before admission to an assistance program.
Homeless/At Risk of Homelessness	Indicate whether or not the family was homeless or at risk of homelessness at the time the Tribe/TDHE admitted the family to a housing assistance program.
UNIT TO BE OCCUPIED ON ACTION EFFECTIVE DATE
Unit Address	The complete address of the housing unit that the household occupies on the effective date of action.
Mailing Address	Provide mailing address if different than unit address to be occupied.
Bedrooms	Total number of bedrooms in the unit that the household will occupy on the effective date of action
Structure Type	Select type from the drop down
Single Family Detached	Building structures that house only one family under one roof
Semi-detached	Includes units in duplexes and two-family homes.
Rowhouse/Townhouse	Includes structures with three or more units side-by-side and under one roof.
Low-rise	Multifamily apartment buildings of five or more units and up to four stories. Also include five or six story buildings without an elevator as low-rise structures.
High Rise Elevator	Buildings of five stories or more with elevators.
Manufactured Home	Includes mobile homes
Lease Start/End	Date Unit Lease Begins and Ends.
Bedroom Difference Justification	Provide justification for over housing family or allowing unit with more bedrooms than needed. Note that any additional rental costs due to over housing cannot be funded with Tribal HUD–VASH or IHBG funds.
Type of Property	Select option from drop down. Tribally/TDHE Owned, Privately Owned or Subsidized with other Federal Assistance
TOTAL TENANT PAYMENT
Total Monthly Tenant Payment	Enter the tenant’s rent contribution. Tenant rent must not exceed 30 percent of the household’s adjusted monthly income.
PROJECT BASED ASSISTANCE
Bedrooms	Total number of bedrooms in the unit that the household will occupy on the effective date of action
Owner Name	Legal Name of the Property Owner where Unit is Located.
Owner TIN/SSN #	Tax identification number (TIN) or Social Security Number (SSN) of the legal unit owner.
Contract Rent	Total monthly rent amount paid to the unit owner in accordance with the lease agreement.
Utility Allowance	If the rental payment does not include all utilities, indicate the monthly allowance amount for tenant supplied utilities that apply to the family occupied unit.
Gross Rent	Identified as Total Rent Amount in Consolidation Notice. Auto Calculates. The unit’s total monthly rent amount is determined by adding the contract rent to owner to the utility allowance.
TTP	Identified as Tenant Rent Contribution in Consolidation Notice. TTP auto calculates based on the amount established in the Total Tenant Payment section.
Contribution Funds	Input the amount the tribe/TDHE paid using funds outside of the Veteran household's contribution and the Tribal HUD-VASH funding (RAP payment).
FMR	Fair Market Rent for the area where unit is located.
110% of FMR	110% of Fair Market Rent for the area where unit is located.
Monthly Rental Assistance Payment (RAP)	Total rental assistance payment (RAP) equals the gross rent of unit minus total tenant payment (TTP).
Total RAP to Owner	Total Rental Assistance Payments made to Owner over the Leasing Period
Is Family Moving In	Is family moving from another unit to this unit
HUD Approval to Exceed 110% of FMR	Was HUD approval obtained for Lease that exceeds 110% of the Fair Market Value.
Justification	Provide justification for lease that exceeds 110% of Fair Market Rent.
TENANT BASED ASSISTANCE
Bedrooms	The unit size (number of bedrooms) listed on the voucher issued to the family. This may be different than the number of bedrooms listed in Unit to be Occupied on Action Effective Date (Number of bedrooms in the unit). Enter 0 (zero) for an efficiency or Single Room Occupancy (SRO) unit.
Owner Name	Legal Name of the Property Owner where Unit is Located.
Owner TIN/SSN #	Tax identification number (TIN) or Social Security Number (SSN) of the legal unit owner.
Rent to Owner	Total monthly rent payable to the unit owner under the lease for the unit. For rental of a manufactured home space, enter the rent to owner for the space including any owner maintenance or management charges for the space.
Utility Allowance	If the rental payment does not include all utilities, indicate the monthly allowance amount for tenant supplied utilities that apply to the family occupied unit.
Gross Rent	Identified as Total Rent Amount in Consolidation Notice. Auto Calculates. The unit’s total monthly rent amount is determined by adding the contract rent to owner to the utility allowance.
TTP	Identified as Tenant Rent Contribution in Consolidation Notice. TTP auto calculates based on the amount established in the Total Tenant Payment section.
Contribution Funds	Input the amount the tribe/TDHE paid using funds outside of the Veteran household's contribution and the Tribal HUD-VASH funding (RAP payment).
FMR	Fair Market Rent for the area where unit is located.
110% of FMR	110% of Fair Market Rent for the area where unit is located.
Rental Assistance Payment (RAP)	Total rental assistance payment (RAP) equals the gross rent of unit minus total tenant payment (TTP).
Total RAP to Owner	Total Rental Assistance Payments made to Owner over the Leasing Period
Is Family Moving In	Is family moving from another unit to this unit
HUD Approval to Exceed 110% of FMR	Was HUD approval obtained for Lease that exceeds 110% of the Fair Market Value.
Justification	Provide justification for lease that exceeds 110% of Fair Market Rent.
Program Code	Structure Type
Tribal HUD VASH Tenant Based Assistance	Single Family Detached
Tribal HUD VASH Project Based Assistance	Semi-detached
	Rowhouse/Townhouse
Yes	Low-rise
No	High Rise Elevator
	Manufactured Home
Relationship Code
Self	Correction
Spouse	Family Correction (Income)
Child	Family Correction (Non-Income)
Parent	TDHE Correction (Income)
Other Adult	TDHE Correction (Non-Income)
Other Child	Type of Actions
Live-in Aide	New Admission
Gender	Annual Reexamination
M	Interim Reexamination
F	End Participation
Other	Historical Adjustment
Ethnicity	Type of Property
Hispanic or Latino	TDHE/Tribally Owned
Not Hispanic or Latino	Privately Owned
	Other Federally Subsidized
	Race
	White
	Black/African American
	American Indian/Alaskan Native
	Asian
	Native Hawaiian/Other Pacific Islander