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. MTW 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.
1c Programs: Public Housing Tenant-based Voucher Project-based Voucher Homeownership Voucher
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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. MTW 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 2k: Indicate if the family currently participates or participated in a supportive services program in the past year (see Section 23).
Line 2n: Use if instructed by HUD. May be used if the PHA needs to include more than one special program code (line 2p).
Line 2p: Indicate if the family participates in a special program.
Note: Please reference the Special Program Codes list for the current options
Line 2q-2u:
Note: PHAs may use these lines for any information they wish to collect. HUD encourages PHAs to use lines 2q through 2u for local initiatives.
Line 2v: Indicate if the family currently participates or participated in an MTW self-sufficiency program in the past year.
Line 2w: If line 2a is End Participation, indicate the 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.
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 |
2v. 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
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2w. 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 2x. Type of Voucher Issuance New Participant Port In Port Out Transfer of Unit |
3. MTW 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(s). 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 A 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: Enter the highest grade or the full years of formal schooling that the household member completed (0-25).
Note: Years of schooling begin with 1st grade (do not count kindergarten or preschool).
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. MTW 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 and successor notices.
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. MTW Unit to be Occupied on Effective Date of Action
Line 5a: The complete address of the housing unit that the household occupies on the effective date of action (line 2b). 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 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
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5f(1). Family requested accessibility features Yes No
5f(2). Type of accessibility features requested Hearing/Vision Mobility Both Partially |
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 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 18a: The name of each family member in the household that has assets and their Member number (line(s) 3a) that corresponds to the asset information reported.
Line 18b: 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 18c: 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 18d: Estimated, known or calculated cash value of the asset listed.
Line 18e: Actual income for the 12-month period under examination from the asset listed.
Line 18f: Estimated imputed income for the 12-month period under examination from the asset listed.
Note: Imputed income is only calculated on assets included in net family assets, if actual asset income cannot be calculated for that particular asset, and the net family assets exceed the current threshold requirement for imputing asset income.
Line 18g: 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 18c.
Line 18h: Total of the values listed in column 18e.
Line 18i: Total of the values listed in column 18f.
Line 18j: Enter the passbook rate as a decimal.
Line 18k: Total amount of household income derived from assets.
19. MTW Income
Note: If the family members do not have any income from sources other than assets and do not expect any other income in the next 12-month period under examination, leave 19a through 19h blank. Fill in total annual income (line 19i), which would be the total of the asset income.
Line 19a: The name of each family member in the household that has income and their Member number (line(s) 3a) that corresponds to the income information reported.
Line 19b: 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 19c: Use this column to perform income calculations.
Line 19d: Annual income amount the family member earns from the income source(s) listed.
Note: See the Form HUD-50058 Instruction Booklet for a description of each income source.
Line 19e: 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 19f: The family’s total income minus any exclusions. Take dollars per year (line 19d) minus income exclusions (line 19e).
Line 19g: The total dollar amounts listed in column 19d.
Line 19h: The total dollar amounts listed in column 19f.
Line 19i: The family’s total annual income. Add the final asset income (line 18k) and the total income after income exclusions (line 19h).
Line 19j: Total amount of money that is deducted from a family’s income for rent determination purposes.
Line 19k: The family’s adjusted annual income. Take total annual income (line 19i) minus deductions (line 19j).
Line 19l: 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 19m: Indicate if the family’s adjusted annual income (line 19k) exceeds the over-income limit.
Line 19n: Line 19n should only be completed if “Y” is selected in 19m. Indicate when the family first began the two-year 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 24 consecutive month grace period and subsequently exceeds it again, the grace period starts over.
19b. Income Codes
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 |
20. MTW Public Housing
Note: Complete if the family’s program type is MTW Public Housing (line 1c=P) and the type of action is New Admission (2a=1), Annual Reexamination (2a=2), Interim Reexamination (2a=3), or Unit Change Only (2a=7).
Line 20a: Indicate whether the family pays an income-based rent or a flat rent.
Note: Flat rent is not set by the family’s income.
Line 20b: The rent amount the family pays to the owner.
Line 20c: The rent amount the mixed family pays to the owner.
Line 20d: If the payment does not include all utilities, indicate the monthly allowance amount for tenant supplied utilities that applies to the family occupied unit or an estimate of the utility costs.
Note: If the tenant rent includes all utilities, enter 0.
Line 20e: Indicate if the family is paying the ceiling rent for this unit.
Line 20f: Reserved.
21. MTW Tenant-Based or Project-Based Assistance
Note: Complete if the family’s program type is (1c=PR) for Project-Based Voucher or (1c=T) for Tenant-Based Voucher 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 21a: Indicate whether the family pays an income-based subsidy or a flat subsidy.
Note: Flat subsidies are not set by the family’s income.
Line 21b: Unit size (number of bedrooms) listed on the family’s voucher equivalent
Line 21c: Indicate if the family is now moving into the unit.
Line 21d: Indicate whether or not the household will move or has moved into the PHA’s jurisdiction under portability.
Line 21e: Monthly amount billed to the initial PHA for the family’s housing assistance payment (HAP), ongoing administrative fee, and any utility reimbursement to the family.
Note: Enter 0 if the family was absorbed by the receiving PHA.
Line 21f: The initial PHA’s 2-letter state code and 3-digit identification number.
Line 21g: The unit owner’s legal name.
Line 21h: Tax identification number (TIN) or Social Security Number (SSN) of the legal unit owner.
Line 21i: Total monthly rent payable to the unit owner under the lease for the contract unit.
Line 21j: If the payment does not include all utilities, indicate the monthly allowance amount for tenant supplied utilities that apply to the family occupied unit or an estimate of utility costs.
Note: If the payment includes all utilities, enter 0.
Line 21k: Gross rent of unit or space rent. Add rent to owner (line 21i) to the utility allowance (line 21j).
Line 21m: Amount of monthly flat subsidy that the PHA provides to unit owner, if any, if line 21a=F.
Line 21n: Rent amount the family pays to the owner.
Line 21p: Rent amount the mixed family pays to the owner
Line 21q: Indicate if the family is paying the ceiling rent for this unit.
Line 21r: Total housing assistance payment (HAP)
Line 21s: Project-Based voucher only. 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 21t: Tenant-Based Voucher only. 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 21u: 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 21v: Indicate whether the PHA provided mobility-related services to the family.
Line 21w: Total financial assistance provided by the PHA to a household when the household is leasing a new unit.
Line 21x: Tenant-Based Voucher only. Total financial assistance provided by the PHA to the landlord when a household is leasing a new TBV unit. Include security deposit in total financial assistance if paid for a family.
22. MTW Homeownership
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 Unit Change Only (2a=7).
Line 22a: Indicate if flat subsidy or income-based subsidy.
Note: Flat subsidies are not set by the family’s income.
Line 22b: Indicate if the family is now moving into the home.
Line 22c: Date of the initial housing quality standards (HQS) inspection.
Line 22d: Indicate whether or not the household will move or has moved into the PHA’s jurisdiction under portability.
Line 22e: Monthly amount billed to the initial PHA for the family’s housing assistance payment (HAP) amount, ongoing administrative fee, and any utility reimbursement to the family.
Note: Enter 0 if the family was absorbed by the receiving PHA.
Line 22f: The initial PHA’s 2-letter state code and 3-digit identification number.
Line 22g: 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 22h: The PHA’s utility allowance for the unit.
Note: If the PHA does not provide a utility allowance, enter an estimate of utility costs.
Line 22i: The amount of PHA’s allowances for the homeowner’s monthly routine maintenance costs, major home repairs and maintenance, and co-op/condominium assessments.
Line 22j: Calculation of tenant’s total cost of homeownership. Sum of 22g through 22i.
Line 22k: Total monthly amount of subsidy the PHA contributes toward homeowners if a flat subsidy is provided to the family.
Line 22m: Total amount the family contributes toward homeownership.
Lien 22n: Indicate the mixed family total family contribution based on the proration calculation.
Line 22p: Indicate if the family is paying the ceiling payment for this unit.
Line 22q: The amount of monthly homeownership assistance payment (HAP).
23. Supportive Services Programs (SSP)/MTW Self-Sufficiency
Note: Complete this section if the family participates in a supportive services program (i.e., Family Self Sufficiency, Resident Opportunity and Self Sufficiency (ROSS) Program, Jobs Plus, or MTW self-sufficiency program).
Line 23a: 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 23b: Check one category to indicate the purpose of the Addendum.
Line 23c: The effective date of the SSP action.
Line 23d: The PHA code associated with the PHA that provides the self-sufficiency services.
Note: For help obtaining the PHA’s identification number, contact the appropriate HUD field office.
Line 23e: Check one category to indicate the purpose of the MTW self-sufficiency Addendum.
Line 23f: The effective date of the MTW self-sufficiency action.
Line 23h(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 23h(2): The date the head of household began their current job.
Line 23h(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 23h(4): Reserved
Line 23h(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 23h(6): The number of children in the household who receive childcare services.
23a. Supportive Services Programs: Family Self-Sufficiency (FSS) ROSS Jobs Plus MTW Self-Sufficiency
23h(1). Employment status: Full-time (32 hours per week or more) Part-time Not employed
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23h(3). Employment benefits: Health Retirement Account Other
23h(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) Social Security (SS) |
Line 23i(1): Indicate whether or not the PHA identified individual training and service needs of the family members participating in the program identified in 23a.
Line 23i(2): For every need identified, indicate whether or not these needs were met during participation in the SS program.
Line 23j(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 23j(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 23j(3): If applicable, the date to which the PHA has extended the family’s contract of participation.
Line 23j(4): The number of family members in the household who have current Individual Training and Services Plans under the contract of participation.
Line 23j(5): For new enrollment, indicate whether or not the family received a selection preference due to participation in a related service program.
Line 23k(1): The current dollar amount credited to the family’s account.
Line 23k(2): The current dollar amount of the family’s account based on the most recent report of account funds and activity.
Line 23k(3): Total dollar cumulative amount, if any, of all interim escrow disbursements ever made to the family.
Line 23m(1): Indicate if the family fulfilled all of its obligations under the contract during the contract term.
Line 23m(2): Indicate if the family completed the contract and is moving to homeownership.
Line 23m(3): If not graduation in (23(m)(1), indicate from the options below why the family exited the program.
23m(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 23n: The PHA code for the PHA that is managing the rental assistance for this FSS participant. May be different than 23d.
MTW Self-Sufficiency Program
Line 23p(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 23p(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 23p(3): If applicable, the date to which the PHA has extended the family's MTW self-sufficiency contract of participation.
Line 23p(4): The number of family members in the household who have current Individual Training and Services Plans under the contract of participation.
Line 23q(1): The current dollar amount credited to the family’s account.
Line 23q(2): The current dollar amount of the family’s account based on the most recent report of account funds and activity.
Line 23q(3): Total dollar cumulative amount, if any, of all interim escrow disbursements ever made to the family.
Line 23r(1): Indicate if the family fulfilled all of its obligations under the contract during the contract term.
Line 23r(2): Indicate if the family completed the contract and is moving to homeownership.
Line 23q(3): If not graduation in (23(m)(1), indicate from the options below why the family exited the program.
23q(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 23s(1): Indicate whether or not the PHA identified individual training and service needs of the family members.
Line 23s(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 | 2024-07-22 |