Household Services and Outcomes Report, 52698

U.S. Department of Housing and Urban Development
Office of Policy Development and Research

OMB Control Number 2528-0331
Expires XX/XX/XXXX

Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. You may send comments regarding this burden estimate or suggestions to reduce this burden to the Department of Housing and
Urban Development (HUD) at PaperworkReductionActOffice@hud.gov. When providing comments, please refer to the Office of Management
and Budget (OMB) Approval No. 2528-0331. Collection of this information is authorized by the Consolidated Appropriations Act, 2021 (Pub.
L. No. 116-260, approved December 27, 2020), Consolidated Appropriations Act, 2022 (Pub. L. No. 117-103, approved March 15, 2022),
Consolidated Appropriations Act, 2023 (Pub. L. No. 117–328, approved December 29, 2022), Consolidated Appropriations Act, 2024 (Pub. L.
No. 118-42, approved March 9, 2024), and Section 502 of the Housing and Urban Development Act of 1970 (Pub. L. No. 91-609) (12 U.S.C. §§
1701z-1; 1701z-2(d) and (g)). This information is being collected to assess program compliance and effectiveness. HUD intends to use this
information for program compliance monitoring and research on program implementation, effectiveness, and impact, including grantee and
tenant outcomes. This information is required to participate in the Eviction Protection Grant Program. HUD will not release any personally
identifiable information pursuant to the Freedom of Information Act. This agency may not conduct or sponsor, and a person is not required to
respond to, a collection of information unless that collection displays a valid OMB control number.

A. Household Served

Eviction Protection Grant Program
Household Services and Outcomes Report
HUD 52698

1. Presenting Tenant
1a. Presenting Tenant Unique ID _____________________________
1b. Limited English Proficiency? ☐ Yes ☐ No
1c. Gender Identity (select all that apply)
☐ Female ☐ Male ☐ Transgender ☐ Non-binary/non-conforming ☐ Prefer not to respond
1d. Race and/or Ethnicity (select all that apply)
☐ American Indian or Alaska Native ☐ Asian ☐ Black or African American ☐ Hispanic or Latino ☐ Middle
Eastern or North African ☐ Native Hawaiian or Pacific Islander ☐ White
2. Household Members
2a. Total number of children living in the household (under age 18) ________
2b. Total number of adults living in the household (age 18 and older) ________
2c. Household member has a disability ☐ Yes ☐ No
3. Family Income
3a. Total annual family income $_________________
3b. Family income group ☐ Extremely Low Income ☐ Very Low Income ☐ Low Income
4. Eviction Risk (select one category that best reflects circumstances at initial engagement)
☐ At risk of eviction ☐ Subject to eviction
5. Rental Housing Unit (at issue in the pending or potential eviction matter)
5a. Rental Housing Unit Physical Address
Number and Street ________________________________________________ Apt ________
City ________________________________ State ___________ ZIP+4 Code________________
County ______________________________
5b. Evicting Party _____________________________
5c. Is the Evicting Party a public housing agency (PHA)? ☐ Yes ☐ No

HUD 52698

5d. Is the presenting tenant’s rent for the unit listed in 5a subsidized by a federal housing program?
☐ HUD Public Housing ☐ HUD Housing Choice Voucher (Section 8) ☐ HUD Project-Based Section 8
☐ Low Income Housing Tax Credit (LIHTC) ☐ USDA Rural Housing ☐ Other ___________________
☐ Yes, but unsure which program ☐ No
5e. Has the presenting tenant sought emergency rental assistance?
☐ Yes, applied for assistance ☐ Yes, approved for or received assistance ☐ Yes, but denied assistance
☐ No ☐ Not applicable, no emergency rental assistance available
5f. Is the presenting tenant’s mailing address at the time of initial engagement the same as the unit address at
issue in the pending or potential eviction matter?
☐ Yes ☐ No

B. Services Provided
6. Service Provider _____________________________
7. Primary Service (select one category that best reflects the level of service provided)
☐ Limited counsel and advice
☐ Limited action/brief service
☐ Negotiated settlement without litigation
☐ Negotiated settlement with litigation
☐ Administrative agency decision
☐ Court decision
☐ Extensive service not resulting in settlement or court or administrative action
☐ Other post-eviction service
8a. Eviction-Related Fair Housing or Civil Rights Service (select all that apply)
☐ Counsel and advice
☐ Representation
8b. Alternative Dispute Resolution Service (select all that apply)
☐ Alternative dispute resolution advocacy
☐ Alternative dispute resolution settlement agreement
9. Additional or Other Services Provided (briefly describe additional or other services provided)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

C. Outcomes
10. Outcomes (select all that apply)
10a. Preserved or Extended Housing (select all that apply)
☐ Prevented eviction filing
☐ Tenancy preserved, tenant remained in home
☐ Lease renewed
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☐ Obtained additional days to move out (number of additional days _________ )
☐ Eviction delayed or stayed
☐ Remedied lockout
☐ Secured alternate housing
10b. Eviction Case Dismissed
☐ Eviction case dismissed with stipulations
☐ Eviction case dismissed without stipulations
10c. Achieved Financial Benefit (select all that apply)
☐ Back rent or rental fees reduced or waived
☐ Secured or maintained short- or long-term housing assistance
☐ Secured or maintained non-housing service or benefit
☐ Avoided or reduced holdover damages, landlord attorney fees, or other costs
10d. Improved Housing Conditions | Civil Rights (select all that apply)
☐ Obtained repairs or improved housing conditions
☐ Restored utilities
☐ Recovered personal property
☐ Remedied discrimination
☐ Obtained reasonable accommodation
☐ Prevented or remediated retaliation
☐ Enforced other tenant rights
10e. Eviction or Displacement
☐ Eviction default judgment
☐ Eviction judgment (not default)
☐ Displacement without eviction judgment
10f. Negotiated Settlement or Other Remedial Outcomes (select all that apply)
☐ Negotiated agreement or settlement
☐ Eviction record sealed or expunged
☐ Satisfaction of judgment
☐ Other
☐ Unknown
11. Additional or Other Outcomes (briefly describe additional or other outcomes)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
12. Presenting Tenant’s Goals Achieved
12a. Was the presenting tenant’s desired outcome achieved?
☐ Yes ☐ Partially ☐ No ☐ Unknown
12b. Explanation ________________________________________________________________
13. Case Duration Number of days engaged ________
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HUD 52698 Instructions
1a. The presenting tenant is the person seeking legal assistance. For item 1a, the service provider named in item 6 must assign a
unique alphanumeric identifier no longer than 16 characters to the presenting tenant, unless the unique identifier was previously
assigned by a known grantee, subrecipient, or contractor providing Eviction Protection Grant Program (EPGP) services to the
presenting tenant. The presenting tenant unique identifier must be consistently used to report all EPGP matters closed so that noncontemporaneous EPGP matters closed with the same presenting tenant are measurable over the grant period of performance. Service
providers may generate unique identifiers for the purposes of HUD 52698 reporting in a manner that protects client confidentiality.
1b. A presenting tenant who, as a result of his, her, or their national origin, does not speak English as a primary language and who has
a limited ability to speak, read, write, or understand.
1c. Select the category or categories that the presenting tenant says best indicates the presenting tenant’s gender identity. Select all
that apply.
1d. Select the category or categories that the presenting tenant says best indicates the presenting tenant’s race and/or ethnicity. Select
all that apply.
American Indian or Alaska Native means individuals with origins in any of the original peoples of North, Central, and South America,
including, for example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat
Traditional Government, Nome Eskimo Community, Aztec, and Maya.
Asian means individuals with origins in any of the original peoples of Central or East Asia, Southeast Asia, or South Asia, including, for
example, Chinese, Asian Indian, Filipino, Vietnamese, Korean, and Japanese.
Black or African American means individuals with origins in any of the Black racial groups of Africa, including, for example, African
American, Jamaican, Haitian, Nigerian, Ethiopian, and Somali.
Hispanic or Latino includes individuals of Mexican, Puerto Rican, Salvadoran, Cuban, Dominican, Guatemalan, and other Central or
South American or Spanish culture or origin.
Middle Eastern or North African means individuals with origins in any of the original peoples of the Middle East or North Africa,
including, for example, Lebanese, Iranian, Egyptian, Syrian, Iraqi, and Israeli.
Native Hawaiian or Pacific Islander means individuals with origins in any of the original peoples of Hawaii, Guam, Samoa, or other
Pacific Islands, including, for example, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, and Marshallese.
White means individuals with origins in any of the original peoples of Europe, including, for example, English, German, Irish, Italian,
Polish, and Scottish.
2a. A household includes all the people who occupy the rental housing unit at issue in the pending or potential eviction matter. For item
2a, indicate the total number of persons under age 18 living in the household.
2b. Indicate the total number of persons age 18 and older living in the household.
2c. Indicate whether or not the presenting tenant or other member of their household has a disability. A person with disabilities has 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, (c) a developmental
disability as defined in Section 102 of the Developmental Disabilities Assistance and Bill of Rights Act or (d) a disability as defined in 24
CFR § 8.3, for purposes of reasonable accommodation and program accessibility for persons with disabilities. Note: Include persons
who have the acquired immune deficiency syndrome (AIDS) or any condition that arises from the etiologic agent for AIDS.
3a. Indicate the family’s total annual income.
3b. Select one category that represents the family’s income relative to the local area median income based on the number of persons in
the household. See HUD’s income limits.
4. Select one category that best reflects the presenting tenant’s circumstances at the time of initial engagement.
At risk of eviction and Subject to eviction have the meanings set forth in the HUD Eviction Protection Grant Program Notice of Funding
Opportunity.
5a. Indicate the physical address of the presenting tenant’s rental housing unit at issue in the pending or potential eviction matter.
Indicate the city, state, full 9-digit ZIP Code, and county at a minimum. Other physical address details (building number, street, and unit
number) are optional for reporting purposes.
5b. Indicate the Evicting Party name in the pending or potential eviction matter with respect to the unit listed in 5a.
Evicting Party has the meaning set forth in the HUD Eviction Protection Grant Program Notice of Funding Opportunity.
5c. Indicate whether the Evicting Party listed in 5b is a public housing authority or agency (PHA).
5d. Indicate whether the presenting tenant’s rent for the unit listed in 5a is subsidized by a federal housing program at the time of initial
engagement. This information may be self-reported by the presenting tenant if documentation or third-party confirmation of a federal
housing subsidy is not available. Do not include short-term emergency rental assistance in item 5d.
5e. Indicate whether the presenting tenant has sought short-term emergency rental assistance through any emergency rent relief
program. Select one category that best reflects the presenting tenant’s circumstances at the time of initial engagement. This information
may be self-reported by the presenting tenant if documentation or third-party confirmation is not available.

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5f. Indicate whether, at the time of initial engagement, the presenting tenant receives mail at the physical rental housing unit at issue in
the pending or potential eviction matter.
6. Indicate name of grantee, subrecipient, or contractor providing service.
7. Select one category that best reflects the highest level of service provided at the time the matter is closed. Note that grantees are not
required to use HUD 52698 for collecting or reporting information about tenant education and outreach services, referral services, court
navigation services, or collaboration work to advance eviction prevention tools or programs. A description of those services, and
associated accomplishments, must be reported in the grantee’s quarterly performance reports and HUD 52699.
Limited counsel and advice means ascertained or reviewed facts, exercised judgment in applying relevant law, and counseled tenant
concerning his, her, or their legal problem.
Limited action/brief service means communications to a third party, preparation of a simple legal document, or assisting a pro se tenant
with preparation of court or other legal documents.
Negotiated settlement without litigation means resolved tenant’s problem through negotiation and settlement without any court or
administrative actions pending.
Negotiated settlement with litigation means resolved tenant’s problem through negotiation and settlement while a court or formal
administrative action was pending, including when the court or administrative agency issues an order memorializing the settlement.
Administrative agency decision means represented tenant in an administrative agency action that resulted in a case-dispositive
decision by the administrative agency or body after a hearing or other formal administrative process.
Court decision means represented tenant in a court proceeding that resulted in a case dispositive decision made by the court.
Extensive service not resulting in settlement or court or administrative action means assistance involving high level of factual
complexity, highly sophisticated legal analysis, drafting of non-routine original pleadings or legal documents, or significant legal
research.
Other post-eviction service has the meaning set forth in the HUD Eviction Protection Grant Program Notice of Funding Opportunity,
unless otherwise captured by services defined above.
8a. Select the category or categories that reflect eviction-related fair housing or civil rights services provided during engagement in the
tenant’s pending or potential eviction matter, if any.
Eviction-related counsel and advice means counsel and legal advice in relation to a fair housing and civil rights matter or filing a fair
housing and civil rights complaint related to an eviction matter.
Eviction-related representation means legal representation or limited representation in relation to a fair housing and civil rights matter or
filing a fair housing and civil rights complaint related to an eviction matter.
8b. Select the category or categories that reflect alternative dispute resolution services provided during engagement in the tenant’s
pending or potential eviction matter, if any.
Alternative dispute resolution advocacy means represented tenant, or assisted tenant with advocating for their interests, in an
alternative dispute resolution process, whether participation was voluntary or ordered by a court.
Alternative dispute resolution settlement agreement means assisted with resolving tenant’s problem through mediation, arbitration,
conciliation, negotiation, transaction, or settlement memorialized by an agreement, whether or not a court or administrative agency
issues an order memorializing the agreement.
9. Briefly describe additional services provided. If applicable, briefly explain “Other” activity or advocacy.
10. Select the category or categories that represent tenant outcomes at the time the matter is closed. Select all that apply.
11. Briefly describe additional outcomes. If applicable, briefly explain “Other” outcomes.
12a. Qualify whether the outcome obtained at the time the matter is closed met the presenting tenant’s goals, as established in
consultation with their lawyer or advocate, for resolution of their matter. The service provider listed in item 6 is to determine whether the
tenant’s goals were met based on their understanding of the tenant’s wishes and the legally available remedies.
12b. Describe any factors or context needed to explain the provider’s response to 12a. For example, if the presenting tenant’s desired
outcomes were only partially achieved or were not legally available based on the facts presented.
13. Indicate the number of days the service provider listed in item 6 was engaged with the presenting tenant in this matter, from the
time of initial engagement to the time the matter is closed.

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