Form HUD-50900 Elements for the Annual Moving to Work Plan and Annual M

OMB Control Number: 2557-0216

Expiration Date: XX/XX/XXXX

FORM 50900: Elements for the Annual Moving to work Plan

and Annual Moving to work Report

Attachment B

to the moving to work Agreement

Between the U.S. Department of Housing and Urban Development

And Moving to work Agencies

HUD is collecting the information in this Form 50900 in order to evaluate the impacts of Moving to Work (MTW) activities, accurately and timely respond to congressional and other inquiries regarding outcome measures, and identify promising practices learned through the MTW demonstration. The information collected through this Form 50900 is not confidential. The Legacy 39 MTW public housing agencies (PHAs) will report outcome information on the effects of MTW policy changes on residents, operations, and the local community. The estimated burden per year, per Legacy MTW PHA, is 81 hours annually. Responses to this collection of information are required to obtain a benefit or to retain a benefit. HUD may not conduct or sponsor, and MTW PHAs are not required to respond to, a collection of information unless that collection displays a valid Office of Management and Budget (OMB) control number.

GENERAL INSTRUCTIONS

Section Numbering: The sections are as follows: (I) Introduction, (II) General Operating Information,

(III) Proposed MTW Activities, (IV) Approved MTW Activities, (V) Planned Application of MTW Funds, and

(VI) Administrative.

Inapplicable Fields and Sections: For those text fields in the tables provided in Sections (II) and (V) that are not applicable, the MTW PHA should insert an “N/A.” For those numerical fields in the tables provided in Sections (II) and (V) that are not applicable or have no value, the MTW PHA should insert a “0” (zero). Where a narrative portion of Sections (I), (III), (IV) or (VI) is not applicable, the MTW PHA should include the sub-section number and/or title and insert an “N/A.”

Plan Year: The “Plan Year” is defined as the MTW PHA’s fiscal year. The Plan Year is generally twelve months, but may be longer or shorter if the MTW PHA is transitioning the start and end of its fiscal year to different dates. The MTW PHA should discuss the impact of such transitioning on Annual MTW Plan/Report submissions with HUD Headquarters and the applicable local HUD Field Office.

Format Requirements: MTW PHAs are required to provide information according to the order in this Form 50900.

• There is no prescribed format for presenting the required information in Sections (I), (III), (IV) or (VI) of this Form 50900, but all required information, outlined in the “Section-by-Section” Instructions, must be clearly provided.

• For Section (II) and Section (V), MTW PHAs must insert the tables as they appear in this Form 50900. These tables must be included in the Annual MTW Plan/Report as provided.

• The submittal of separate Excel versions of Section (II) and Section (V) is not required.

• MTW PHAs must present the applicable Standard Metrics in Sections (III) and Section (IV) in the table format given in the “Standard HUD Metrics” section of this Form 50900.

• HUD prefers that MTW PHAs also report agency-developed metric information in a similar format.

Submission Requirements (dissemination): The MTW PHA shall follow the submission requirements as set forth in its current MTW Agreement. All initial and revised submissions of the Annual MTW Plan and the Annual MTW Report must be sent in an electronic format to HUD Headquarters and the applicable local HUD Field Office via email. The MTW Coordinator will send an email confirming receipt after the submission is received.

Submission Requirements (file type): The electronic submission shall include a searchable PDF version (not a scanned PDF) of the Annual MTW Plan/Report or a Microsoft Word document version of the Annual MTW Plan/Report. The body of the Annual MTW Plan/Report shall be submitted as one file type and preferably in one file. The body shall include the HUD-generated tables for Sections (II) and (V) and the applicable Standard HUD Metrics tables incorporated into Sections (III) and (IV). Supplemental materials (e.g. signed Board Resolution and other appendix information) may be submitted in a different file type.

Submission Requirements (hard copy): A hard copy submission by the MTW PHA is only necessary at the request of HUD.

SECTION-BY-SECTION INSTRUCTIONS

SECTION I: INTRODUCTION

Generally: MTW PHAs will include both short-term and long-term MTW goals and objectives in this section.

SECTION II: GENERAL OPERATING INFORMATION

Generally: Pre-formatted tables have been provided in this Form 50900 for MTW PHAs to provide the required housing stock, leasing and waiting list information in this section. These tables must be included in the Annual MTW Plan/Report as provided. The MTW PHA may include clarifying text in addition to these tables in the Annual MTW Plan/Report. An MTW PHA may also include updates to its historical housing stock or leasing tables as an appendix to the Annual MTW Plan/Report. The MTW PHA may reference such an appendix in Section (II) to direct readers to this information.

Section II.A: Housing Stock Information

General Description of All Planned Capital Expenditures: MTW PHAs are required to provide a general description and amounts of planned capital expenditures by development. Please note, this narrative should include all planned capital expenditures using MTW funding flexibilities, not just Capital Fund Program expenditures.

Section II.B: Leasing Information

Definition of MTW Households Served: "MTW Households Served" include all households that receive housing assistance, directly or indirectly, using any amount of MTW funds. Housing assistance through local, non-traditional MTW programs is included, as long as the activity conforms to the requirements stipulated in the Standard MTW Agreement and PIH Notice 2011-45 (or applicable successor MTW Agreement and/or PIH Notice).

Categories of MTW Households Served: “MTW Households Served” data will be reported in the categories defined below. These categories are the only households that will be considered in the “Total Households Served/Units Leased” calculation used to determine if the MTW PHA is continuing to assist substantially the same total number of eligible low-income families as it would have, had the MTW PHA not combined its funds (as set forth in PIH Notice 2013-2 or successor PIH Notice).

• MTW Public Housing Units Leased: Number of households that reside in any unit of public housing authorized and funded under an Annual Contributions Contract (ACC) between the MTW PHA and HUD pursuant to the U.S. Housing Act of 1937.

• MTW Housing Choice Vouchers (HCVs) Utilized: Number of households that receive rental assistance through Housing Assistance Payment (HAP) Contracts (pursuant to an ACC between HUD and the MTW PHA) paid for with MTW funds at a location selected by the household and not tied to a specific location OR households that receive rental assistance through HAP Contracts (pursuant to an ACC between HUD and the PHA) paid for with MTW funds at a specific location that is not public housing. This number must not include port-in HCVs not paid for by the MTW PHA.

• Local, Non-Traditional: Tenant-Based: Number of households that receive assistance through an MTW tenant-based housing program outside of Sections 8 and 9 of the U.S. Housing Act of 1937. This includes all households at or below 80% area median income (AMI) that receive tenant-based housing assistance through MTW funds but not through traditional public housing or HCVs.

• Local, Non-Traditional: Property-Based: Number of households that receive assistance through an MTW property-based or project-based housing program outside of Sections 8 and 9 of the U.S. Housing Act of 1937. This includes all households at or below 80% AMI that receive property-based housing assistance through MTW funds but not through traditional public housing or HCVs.

• Local, Non-Traditional: Homeownership: Number of households that receive assistance through an MTW homeownership housing program outside of Sections 8 and 9 of the U.S. Housing Act of 1937. This includes all households at or below 80% AMI that receive homeownership housing assistance through MTW funds but not through traditional public housing or HCVs.

Households Receiving Services Only: HUD will track “Households Receiving Services Only through MTW-Funded Local, Non-Traditional Activities.” These households, however, will not be considered in the “Total Households Served/Units Leased” calculation used to determine if the MTW PHA is continuing to assist substantially the same total number of eligible low-income families as it would have had the MTW PHA not combined its funds (as set forth in PIH Notice 2013-2 or successor PIH Notice). The definition for households tracked in this category is:

• Households Receiving Services Only: Number of households at or below 80% AMI provided services through MTW funds and not assisted through any type of housing assistance for the Plan Year and over the course of the MTW PHA's participation in the demonstration. Households that are only receiving services and are also on one or more of the MTW PHA's housing waiting lists should be included in this category.

Section II.C: Waiting List Information

Waiting List Information Submittal: This section will include those waiting lists managed by the MTW PHA and those managed by a third party. MTW PHAs should provide information only on those waiting lists that contain households in the “MTW Households Served” categories defined above for Section II.B. Waiting lists for households receiving services only and households in other non-MTW housing programs should not be included.

SECTION III: PROPOSED MTW ACTIVITIES and SECTION IV: APPROVED MTW ACTIVITIES

Use of Standard HUD Metrics: MTW PHAs are required to track all applicable "Standard HUD Metrics" under each implicated statutory objective for each MTW activity. Standard HUD Metrics must be given in the table format provided in the "Standard HUD Metrics" section of this Form 50900 in order to allow analysis and aggregation across MTW PHAs for similar activities.

When proposing an MTW activity, the MTW PHA should provide the Standard HUD Metrics it deems applicable to that activity. After review of the proposed activity, HUD will determine the Standard HUD Metrics that the MTW PHA must provide. After the activity has been approved, HUD will advise the MTW PHA of any necessary changes to the applicable Standard HUD Metrics.

Additional Metrics: MTW PHAs may report on agency-developed and previously established metrics in addition to the required Standard HUD Metrics.

SECTION IV: APPROVED MTW ACTIVITIES

Generally: This section includes four subsections: Implemented, Not Yet Implemented, On Hold, and Closed Out. Once an activity is approved it must be placed in Section (IV) under one of these four subsections. These subsections are defined below.

• Implemented Activities: MTW activities in which the MTW PHA is actively engaged.

• Not Yet Implemented Activities: MTW activities in which the MTW PHA is not actively engaged but is preparing to implement in the future.

• On Hold Activities: MTW activities that were previously implemented, that the MTW PHA stopped implementing, but that the MTW PHA plans to reactivate in the future.

• Closed Out Activities: MTW activities that

• Were MTW activities, but are now obsolete because they no longer require MTW flexibility due to changes in regulation;

• Were completed because the MTW PHA accomplished its stated objectives and no longer requires the use of MTW flexibility;

• The MTW PHA has decided to end before attaining the activity's objectives; or

• The MTW PHA has never implemented and does not plan to implement at any point in the future.

In the year the activity is ended the MTW PHA is required to provide information about the outcomes of the activity.

Use of Standard HUD Metrics: Standard HUD Metrics must be shown in the table format provided in the "Standard HUD Metrics" section of this Form 50900 in order to allow analysis and aggregation across MTW PHAs for similar activities. Standard HUD Metrics should appear in the Section (IV) subsections as follows:

• Implemented Activities: MTW PHAs are required to track all of the applicable Standard HUD Metrics under each statutory objective implicated.

• Not Yet Implemented Activities: Since the MTW PHA would not currently be engaged in this category of approved activities, it is not necessary to include applicable Standard HUD Metrics until implementation.

• On Hold Activities: Since the MTW PHA would not currently be engaged in this category of approved activities, it is not necessary to include applicable Standard HUD Metrics until implementation.

• Closed Out Activities: MTW PHAs are required to provide final information on all of the applicable Standard HUD Metrics under each statutory objective implicated for activities approved and implemented after calendar year 2012.

Closing Out Activities: An approved activity must be closed out in an Annual MTW Report. If an Annual MTW Plan is to be submitted after the MTW PHA has decided to close the activity but prior to the submission of an Annual MTW Report, the to-be-closed activity should be listed in the “Not Yet Implemented Activities” or the “On Hold Activities” subsection of the Annual MTW Plan as applicable. The associated discussion and timeline should indicate that the MTW PHA will close out the activity in the next Annual MTW Report.

Significant Changes to Activities: HUD requires MTW PHAs to re-propose activities that require "significant changes." A "significant change" occurs when the nature of the activity has changed such that an additional MTW authorization is needed OR when an MTW PHA fundamentally changes the nature and scope of an activity to the extent that there is the potential for a different impact on residents (e.g. changing the calculation of rent). In these cases, the activity must undergo a new public process. HUD reserves the right to determine on a case-by-case basis if the change made to an activity crosses this threshold and therefore requires the activity to be re-proposed.

SECTION V: PLANNED APPLICATION OF MTW FUNDS

Generally: Pre-formatted tables have been provided in this Form 50900 for MTW PHAs to provide the required information in this section. These tables must be included in the Annual MTW Plan/Report as provided. The MTW PHA may include clarifying text in addition to these tables in the Annual MTW Plan/Report.

Note: the information collected in this section is to fulfill MTW programmatic reporting requirements and does not replace the MTW PHA’s obligation to annually complete its audited financial statements through HUD’s Financial Data Schedule (FDS).

SECTION VI: ADMINISTRATIVE

Board Resolution Submittal: There is no predetermined format for submission with the Annual MTW Plan of the required resolution signed by the Board of Commissioners (or other authorized MTW PHA governing body) adopting the Annual MTW Plan and the Annual MTW Plan Certifications of Compliance.

Certification of Meeting the MTW Statutory Requirements Submittal: There is no predetermined format for submission with the Annual MTW Report of the required certification that the MTW PHA has met the three MTW statutory requirements.

Certifications of Compliance Submittal: The format for submission with the Annual MTW Plan of the required Certifications of Compliance is provided in this Form 50900. The preamble to the Certifications of Compliance directs the MTW PHA to fill in the beginning of the Plan Year for which the certification is being made. This should be provided as the first day of the Plan Year to be covered by the Annual MTW Plan (for example, for a FY2017 Annual MTW Plan for an MTW PHA with a Plan Year of January 1 – December 31, this would be January 1, 2017).

ADDITIONAL ITEMS

Appendix Information Submittal: The MTW PHA may submit additional appendix items as it deems appropriate. Particular MTW PHAs may be required to submit additional appendix items depending on the content of the particular MTW Agreement and Annual MTW Plan (examples include RHF Plan, Local Asset Management Plan, RAD Significant Amendment, Hardship Policy, etc.) All appendices should be listed in the table of contents and available for the purposes of the MTW PHA’s public process. Beyond inclusion in the MTW PHA’s Annual Plan, the Hardship Policy Appendix will not be considered by HUD as part of its approval process.

Submittal of Implementing Documents: As a part of the Annual MTW Plan and/or Annual MTW Report submission, the MTW PHA may not submit to HUD for approval implementing documents (such as Administrative Plans, Admission and Continued Occupancy Plans (ACOPs), etc.) or other materials that are superfluous to the items in this Form 50900. HUD may request that the MTW PHA separate such items from the Annual MTW Plan to be approved and/or Annual MTW Report to be accepted.

1. INTRODUCTION

Annual MTW Plan	Annual MTW Report
A. TABLE OF CONTENTS Include all of the required elements of the Annual MTW Plan (including appendices).	A. TABLE OF CONTENTS Include all the required elements of the Annual MTW Report (including appendices).
B. OVERVIEW OF SHORT-TERM AND LONG-TERM MTW GOALS AND OBJECTIVES Short-term goals and objectives include those that the MTW PHA plans to accomplish during the Plan Year. Long-term goals and objectives include those that the MTW PHA plans to accomplish beyond the current Plan Year. MTW PHAs have the ability to define the level of specificity in the short-term and long-term goals and objectives. If the MTW PHA includes non-MTW components, the MTW PHA should clearly delineate which are MTW and which are non-MTW goals and objectives. MTW PHAs have the flexibility to include references to proposed and ongoing activities in this section if it assists in providing an explanation about short-term and long-term goals and objectives. However, this is not required.	B. OVERVIEW OF SHORT-TERM AND LONG-TERM MTW GOALS AND OBJECTIVES The MTW PHA should include information about whether the short-term goals and objectives provided in the corresponding Annual MTW Plan were accomplished. MTW PHAs should report progress towards the long-term goals and objectives provided in the corresponding Annual MTW Plan.

2. GENERAL OPERATING INFORMATION

Annual MTW Plan

1. HOUSING STOCK INFORMATION

1. Planned New Public Housing Units

New public housing units that the MTW PHA anticipates will be added during the Plan Year.

ASSET MANAGEMENT PROJECT (AMP) FILL IN NAME AND NUMBER	0/1 Bdm	2 Bdm	3 Bdm	4 Bdm	5 Bdm	6+ Bdm	TOTAL UNITS	POPULATION TYPE**	Section 504 Accessible Units* (Mobility)	Section 504 Units* (Hearing / Vision)
Name/Number	#	#	#	#	#	#	#	Type (below)	#	#
Name/Number	#	#	#	#	#	#	#	Type (below)	#	#
Name/Number	#	#	#	#	#	#	#	Type (below)	#	#

Total Public Housing Units to be Added in the Plan Year:

#

* The federal accessibility standard under HUD’s Section 504 regulation is the Uniform Federal Accessibility Standards (UFAS) for purposes of Section 504 compliance (24 CFR 8.32). HUD recipients may alternatively use the 2010 ADA Standards for Accessible Design under Title II of the ADA, except for certain specific identified provisions, as detailed in HUD’s Notice on “Instructions for use of alternative accessibility standard,” published in the Federal Register on May 23, 2014 (“Deeming Notice”) for purposes of Section 504 compliance, https://www.govinfo.gov/content/pkg/FR-2014-05-23/pdf/2014-11844.pdf

** Select “Population Type” from: General, Elderly, Disabled, Elderly/Disabled, Other

If “Population Type” is “Other” please describe:

Description

2. Planned Public Housing Units to be Removed

Public housing units that the MTW PHA anticipates will be removed during the Plan Year.

AMP NAME AND NUMBER	NUMBER OF UNITS TO BE REMOVED	EXPLANATION FOR REMOVAL
Name/Number	#	Explanation
Name/Number	#	Explanation
Name/Number	#	Explanation
TOTAL: Public Housing Units to be Removed in the Plan Year	#

3. Planned New Project Based Vouchers

Tenant-based vouchers that the MTW PHA anticipates project-basing for the first time during the Plan Year. These include only those in which at least an Agreement to enter into a Housing Assistance Payment (AHAP) will be in place by the end of the Plan Year. Indicate whether the unit is included in the Rental Assistance Demonstration (RAD).

PROPERTY NAME	NUMBER OF VOUCHERS TO BE PROJECT-BASED	RAD?	DESCRIPTION OF PROJECT
Name	#	Yes/No	Description
Name	#	Yes/No	Description
TOTAL: Planned new Project Based Units in Plan Year	#

4. Existing Project Based Vouchers

Tenant-based vouchers that the MTW PHA is currently project-basing in the Plan Year. These include only those in which at least an AHAP is already in place at the beginning of the Plan Year. Select one of the of the following to indicate the *“Planned Status by the end of the Plan Year: “Committed,” “Leased,” or “Issued.” In column three, indicate whether the unit is included in RAD.

PROPERTY NAME	NUMBER OF PROJECT-BASED VOUCHERS	PLANNED STATUS AT END OF PLAN YEAR*	RAD?	DESCRIPTION OF PROJECT
Name	#	Status (below)	Yes/No	Description
Name	#	Status (below)	Yes/No	Description
Total: Planned Existing Project-Based Vouchers	#

5. Planned Other Changes to MTW Housing Stock Anticipated During the Plan Year

Examples of the types of other changes can include (but are not limited to): units held off-line due to relocation or substantial rehabilitation, local, non-traditional units to be acquired/developed, etc.

PLANNED OTHER CHANGES TO MTW HOUSING STOCK ANTICIPATED IN THE PLAN YEAR

Description

6. General Description of All Planned Capital Expenditures During the Plan Year

Narrative general description of all planned capital expenditures of MTW funds during the Plan Year.

GENERAL DESCRIPTION OF ALL PLANNED CAPITAL EXPENDITURES DURING THE PLAN YEAR

Description

2. LEASING INFORMATION

1. Planned Number of Households Served

Snapshot and unit month information on the number of households the MTW PHA plans to serve at the end of the Plan Year.

PLANNED NUMBER OF HOUSEHOLDS SERVED THROUGH:	PLANNED NUMBER OF UNIT MONTHS OCCUPIED/LEASED*	PLANNED NUMBER OF HOUSEHOLD TO BE SERVED**
MTW Public Housing Units Leased	#	#
MTW Housing Choice Vouchers (HCV) Utilized	#	#
Local, Non-Traditional: Tenant-Based^	#	#
Local, Non-Traditional: Property-Based^	#	#
Local, Non-Traditional: Homeownership^	#	#
Planned Total Households Served:	#	#

* “Planned Number of Unit Months Occupied/Leased” is the total number of months the MTW PHA plans to have leased/occupied in each category throughout the full Plan Year.

** “Planned Number of Households to be Served” is calculated by dividing the “Planned Number of Unit Months Occupied/Leased” by the number of months in the Plan Year.

^ In instances when a local, non-traditional program provides a certain subsidy level but does not specify a number of units/households to be served, the MTW PHA should estimate the number of households to be served.

LOCAL, NON-TRADITIONAL CATEGORY	MTW ACTIVITY NAME/NUMBER	PLANNED NUMBER OF UNIT MONTHS OCCUPIED/LEASED*	PLANNED NUMBER OF HOUSEHOLDS TO BE SERVED*
Tenant-Based	Name/#	#	#
Property-Based	Name/#	#	#
Homeownership	Name/#	#	#

* The sum of the figures provided should match the totals provided for each local, non-traditional categories in the previous table. Figures should be given by individual activity. Multiple entries may be made for each category, if applicable.

2. Discussion of Any Anticipated Issues/Possible Solutions Related to Leasing

Discussions of any anticipated issues and solutions in the MTW housing programs listed.

HOUSING PROGRAM	DESCRIPTION OF ANTICIPATED LEASING ISSUES AND POSSIBLE SOLUTIONS
MTW Public Housing	Description
MTW Housing Choice Voucher	Description
Local, Non-Traditional	Description

3. WAITING LIST INFORMATION

1. Waiting List Information Anticipated

Snapshot information of waiting list data as anticipated at the beginning of the Plan Year. The “Description” column should detail the structure of the waiting list and the population(s) served.

WAITING LIST NAME	DESCRIPTION	NUMBER OF HOUSEHOLDS ON WAITING LIST	WAITING LIST OPEN, PARTIALLY OPEN OR CLOSED	PLANS TO OPEN THE WAITING LIST DURING THE PLAN YEAR
Name	Description	#	Open/Partially Open/Closed	Yes/No
Name	Description	#	Open/Partially Open/Closed	Yes/No
Name	Description	#	Open/Partially Open/Closed	Yes/No

Please describe any duplication of applicants across waiting lists:

Description

2. Planned Changes to Waiting List in the Plan Year

Please describe any anticipated changes to the organizational structure or policies of the waiting list(s), including any opening or closing of a waiting list, during the Plan Year.

WAITING LIST NAME	DESCRIPTION OF PLANNED CHANGES TO WAITING LIST
Name	Description
Name	Description

2. GENERAL OPERATING INFORMATION

Annual MTW REPORT

1. HOUSING STOCK INFORMATION

1. Actual New Project Based Vouchers

Tenant-based vouchers that the MTW PHA project-based for the first time during the Plan Year. These include only those in which at least an Agreement to enter into a Housing Assistance Payment (AHAP) was in place by the end of the Plan Year. Indicate whether the unit is included in the Rental Assistance Demonstration (RAD).

PROPERTY NAME	NUMBER OF VOUCHERS NEWLY PROJECT-BASED (Planned*)	NUMBER OF VOUCHERS NEWLY PROJECT-BASED (Actual)	STATUS AT END OF PLAN YEAR**	RAD?	DESCRIPTION OF PROJECT
Name	#	#	Status (below)	Yes/No	Description
Name	#	#	Status (below)	Yes/No	Description
Total: Planned or Actual Newly Project-Based	#	#

* Figures in the “Planned” column should match the corresponding Annual MTW Plan.

** Select “Status at the End of Plan Year” from: Committed, Leased/Issued

Please describe differences between the Planned and Actual Number of Vouchers Newly Project-Based:

Description

2. Actual Existing Project Based Vouchers

Tenant-based vouchers that the MTW PHA is currently project-basing in the Plan Year. These include only those in which at least an AHAP was in place by the beginning of the Plan Year. Indicate whether the unit is included in RAD.

PROPERTY NAME	NUMBER OF PROJECT-BASED VOUCHERS (Planned*)	NUMBER OF PROJECT-BASED VOUCHERS (Actual)	STATUS AT END OF PLAN YEAR**	RAD?	DESCRIPTION OF PROJECT
Name	#	#	Status (below)	Yes/No	Description
Name	#	#	Status (below)	Yes/No	Description
Total: Planned and Actual Existing Project-Based	#	#

* Figures and text in the “Planned” column should match the corresponding Annual MTW Plan.

** Select “Status at the End of Plan Year” from: Committed, Leased/Issued

Please describe differences between the Planned and Actual Existing Number of Vouchers Project-Based:

Description

3. Actual Other Changes to MTW Housing Stock in the Plan Year

Examples of the types of other changes can include (but are not limited to): units held off-line due to relocation or substantial rehabilitation, local, non-traditional units to be acquired/developed, etc.

ACTUAL OTHER CHANGES TO MTW HOUSING STOCK IN THE PLAN YEAR

Description

4. General Description of All Actual Capital Expenditures During the Plan Year

Narrative general description of all actual capital expenditures of MTW funds during the Plan Year.

GENERAL DESCRIPTION OF ALL ACTUAL CAPITAL EXPENDITURES DURING THE PLAN YEAR

Description

2. LEASING INFORMATION

1. Actual Number of Households Served

Snapshot and unit month information on the number of households the MTW PHA actually served at the end of the Plan Year.

NUMBER OF HOUSEHOLDS SERVED THROUGH:	NUMBER OF UNIT MONTHS OCCUPIED or LEASED* Planned^^	NUMBER OF UNIT MONTHS OCCUPIED or LEASED* Actual	NUMBER OF HOUSEHOLDS SERVED** Planned^^	NUMBER OF HOUSEHOLDS SERVED** Actual
MTW Public Housing Units Leased	#	#	#	#
MTW Housing Choice Vouchers (HCV) Utilized	#	#	#	#
Local, Non-Traditional: Tenant-Based	#	#	#	#
Local, Non-Traditional: Property-Based	#	#	#	#
Local, Non-Traditional: Homeownership	#	#	#	#
Planned and Actual Totals:	#	#	#	#

* “Planned Number of Unit Months Occupied or Leased” is the total number of months the MTW PHA planned to have leased or occupied in each category throughout the full Plan Year (as shown in the Annual MTW Plan).

** “Planned Number of Households to be Served” is calculated by dividing the “Planned Number of Unit Months Occupied or Leased” by the number of months in the Plan Year (as shown in the Annual MTW Plan).

^^ Figures and text in the “Planned” column should match the corresponding Annual MTW Plan.

Please describe any differences between the planned and actual households served:

Description

LOCAL, NON-TRADITIONAL CATEGORY	MTW ACTIVITY (NAME and NUMBER)	NUMBER OF UNIT MONTHS OCCUPIED or LEASED Planned^^	NUMBER OF UNIT MONTHS OCCUPIED or LEASED Actual	NUMBER OF HOUSE-HOLDS SERVED Planned^^	NUMBER OF HOUSE-HOLDS SERVED Actual
Tenant-Based	Name/#	#	#	#	#
Property-Based	Name/#	#	#	#	#
Homeownership	Name/#	#	#	#	#

Planned and Actual Totals

#

#

#

#

* The sum of the figures provided should match the totals provided for each Local, Non-Traditional category in the previous table. Figures should be given by individual activity. Multiple entries may be made for each category if applicable.

^^ Figures and text in the “Planned” column should match the corresponding Annual MTW Plan.

HOUSEHOLDS RECEIVING LOCAL, NON-TRADITIONAL SERVICES ONLY	AVERAGE NUMBER OF HOUSEHOLDS PER MONTH	TOTAL NUMBER OF HOUSEHOLDS IN THE PLAN YEAR
Program Name/Services Provided	#	#

2. Discussion of Any Actual Issues/Solutions Related to Leasing

Discussion of any actual issues and solutions utilized in the MTW housing programs listed.

HOUSING PROGRAM	DESCRIPTION OF ACTUAL LEASING ISSUES AND SOLUTIONS
MTW Public Housing	Description
MTW Housing Choice Voucher	Description
Local, Non-Traditional	Description

3. WAITING LIST INFORMATION

1. Actual Waiting List Information

Snapshot information on the actual status of MTW waiting lists at the end of the Plan Year. The “Description” column should detail the structure of the waiting list and the population(s) served.

WAITING LIST NAME	DESCRIPTION	NUMBER OF HOUSEHOLDS ON WAITING LIST	WAITING LIST STATUS (OPEN, PARTIALLY OPEN OR CLOSED)	WAS THE WAITING LIST OPENED DURING THE PLAN YEAR
Name	Description	#	Open/Partially Open/Closed	Yes/No
Name	Description	#	Open/Partially Open/Closed	Yes/No
Name	Description	#	Open/Partially Open/Closed	Yes/No

Please describe any duplication of applicants across waiting lists:

Description

2. Actual Changes to Waiting List in the Plan Year

Please describe any actual changes to the organizational structure or policies of the waiting list(s), including any opening or closing of a waiting list, during the Plan Year.

WAITING LIST NAME	DESCRIPTION OF ACTUAL CHANGES TO WAITING LIST
Name	Description
Name	Description

4. INFORMATION ON STATUTORY OBJECTIVES AND REQUIREMENTS

1. 75 percent of Families Assisted Are Very Low Income

HUD will verify compliance with the statutory requirement that at least 75 percent of the households assisted by the MTW PHA are very low income for MTW public housing units and MTW HCVs through HUD systems. The MTW PHA should provide data for the actual families housed upon admission during the PHA’s Plan Year reported in the “Local, Non-Traditional: Tenant-Based”; “Local, Non-Traditional: Property-Based”; and “Local, Non-Traditional: Homeownership” categories. Do not include households reported in the “Local, Non-Traditional Services Only” category.

INCOME LEVEL	NUMBER OF LOCAL, NON-TRADITIONAL HOUSEHOLDS ADMITTED IN THE PLAN YEAR
80%-50% Area Median Income	#
49%-30% Area Median Income	#
Below 30% Area Median Income	#
Total Local, Non-Traditional Households Admitted	#

2. Maintain Comparable Mix

HUD will verify compliance with the statutory requirement that MTW PHAs continue to serve a comparable mix of families by family size by first assessing a baseline mix of family sizes served by the MTW PHA prior to entry into the MTW demonstration (or the closest date with available data) and compare that to the current mix of family sizes served during the Plan Year.

BASELINE MIX OF FAMILY SIZES SERVED (upon entry to MTW)

FAMILY SIZE	OCCUPIED PUBLIC HOUSING UNITS	UTILIZED HCVs	NON-MTW ADJUSTMENTS*	BASELINE MIX NUMBER	BASELINE MIX PERCENTAGE
1 Person	#	#	#	#	#%
2 Person	#	#	#	#	#%
3 Person	#	#	#	#	#%
4 Person	#	#	#	#	#%
5 Person	#	#	#	#	#%
6+ Person	#	#	#	#	#%
TOTAL	#	#	#	#	#%

* “Non-MTW Adjustments” are defined as factors that are outside the control of the MTW PHA and/or unrelated to the MTW PHA’s local MTW program. An example of an acceptable “Non-MTW Adjustment” would include demographic changes in the community’s overall population. If the MTW PHA includes “Non-MTW Adjustments,” a thorough justification, including information substantiating the numbers given, should be included below. MTW PHAs must continue to adhere to all fair housing obligations as detailed in the MTW Certifications of Compliance.

Please describe the justification for any “Non-MTW Adjustments” given above:

Description

MIX OF FAMILY SIZES SERVED (in Plan Year)

FAMILY SIZE	BASELINE MIX PERCENTAGE**	NUMBER OF HOUSEHOLDS SERVED IN PLAN YEAR^	PERCENTAGE OF HOUSEHOLDS SERVED IN PLAN YEAR^^	PERCENTAGE CHANGE FROM BASELINE YEAR TO CURRENT PLAN YEAR
1 Person	#%	#	#%	#%
2 Person	#%	#	#%	#%
3 Person	#%	#	#%	#%
4 Person	#%	#	#%	#%
5 Person	#%	#	#%	#%
6+ Person	#%	#	#%	#%
TOTAL	#%	#	#%	#%

** The “Baseline Mix Percentage” figures given in the “Mix of Family Sizes Served (in Plan Year)” table should match those in the column of the same name in the “Baseline Mix of Family Sizes Served (upon entry to MTW)” table.

^ The “Total” in the “Number of Households Served in Plan Year” column should match the “Actual Total” box in the “Actual Number of Households Served in the Plan Year” table in Section II.B.i of this Annual MTW Report.

^^ The percentages in this column should be calculated by dividing the number in the prior column for each family size by the “Total” number of households served in the Plan Year. These percentages will reflect adjustment to the mix of families served that are due to the decisions of the MTW PHA. Justification of percentages in the current Plan Year that vary by more than 5% from the Baseline Year must be provided below.

Please describe the justification for any variances of more than 5% between the Plan Year and Baseline Year:

Description

3. Number of Households Transitioned to Self-Sufficiency in the Plan Year

Number of households, across MTW activities, that were transitioned to the MTW PHA’s local definition of self-sufficiency during the Plan Year.

MTW ACTIVITY (NAME and NUMBER)	NUMBER OF HOUSEHOLDS TRANSITIONED TO SELF SUFFICIENCY*	MTW PHA LOCAL DEFINITION OF SELF-SUFFICIENCY
Name and Number	#	Definition
Name and Number	#	Definition
Name and Number	#	Definition
	#	(Households Duplicated Across MTW Activities)
	#	Total Households Transitioned to Self-Sufficiency

* Figures should match the outcome reported for all activities where the goal of increased self-sufficiency is used in Section IV of this Annual MTW Report.

PROPOSED MTW ACTIVITIES: HUD Approval RequestedAnnual MTW Plan

All required elements given below must be included in the body of the Annual MTW Plan, grouped by each proposed MTW activity. For metrics information, MTW PHAs must follow the guidelines from the “Standard HUD Metrics” section of this Form 50900. MTW PHAs must report all applicable Standard HUD Metrics for each activity as assigned by HUD.

1. ACTIVITY DESCRIPTION

1. Describe the proposed activity.

2. Describe how the proposed activity will achieve one or more of the three statutory objectives and the specific impacts on that statutory objective(s).

3. Provide the anticipated schedule for implementing the proposed activity.

2. ACTIVITY METRICS INFORMATION

1. Provide the metrics from the “Standard HUD Metrics” section that are applicable to the proposed activity.

2. Give the baseline performance level for each metric (a numeric value) prior to the implementation of the proposed activity.

3. Give the annual benchmark for each metric (a numeric value).

4. If applicable, give the overall and/or long-term benchmark(s) for each metric (a numeric value).

5. Give the data source from which the metric data will be compiled.

3. COST IMPLICATIONS

1. State whether the proposed activity will result in any cost implications (positive and/or negative) for the MTW PHA.

2. If the proposed activity does result in cost implications, provide an estimate of the amount and discuss how the MTW PHA will manage the surplus or deficit anticipated.

4. NEED/JUSTIFICATION FOR MTW FLEXIBILITY

1. Cite the authorization(s) detailed in Attachment C and/or D of the Standard MTW Agreement (or applicable successor section in future iterations of the MTW Agreement) that gives the MTW PHA flexibility to conduct the proposed activity.

2. Explain why the cited authorization(s) is needed to engage in the proposed activity.

Every reasonable effort should be made by the MTW PHA to reference the complete and correct authorization(s) that are applicable to a particular activity when proposing the activity. A failure to cite the correct or entire statue or regulation will require a technical revision to the activity to include the correct authorization(s).

5. RENT REFORM/TERM LIMIT INFORMATION (if applicable)

HUD defines “rent reform” as any change to how rent/tenant share is calculated for a household that would not be allowable absent the MTW activity. Any MTW activity that an MTW PHA enacts that alters the rent calculation (the amount a household contributes towards their housing costs) would be considered a type of rent reform. The following information must be provided for all rent reform activities. In addition, any MTW activity that seeks to adopt a term limit in the public housing program must include information on items (ii)-(iv).

1. IMPACT ANALYSIS

The MTW PHA may provide an impact analysis for each component of the rent reform activity or a comprehensive impact analysis of the rent reform activity. To assess the impacts of the rent reform activity, the following steps are suggested:

1. A description of how the proposed MTW activity will impact household rent/tenant share.

2. A description of how the MTW PHA will implement and track the rent reform activity and how that process will enable the identification of any unintended consequences/impacts.

3. A numerical analysis detailing the intended/possible impacts of the rent reform activity (including changes to the amount of rent/tenant share, rent burden increases/decreases, households affected, etc.)

4. A plan for how the MTW PHA will weigh the consequences/benefits of the rent reform activity to determine whether it should be adjusted/terminated/reduced/continued/expanded.

2. HARDSHIP CASE CRITERIA
   The MTW PHA must establish a hardship policy that clearly defines the circumstances under which households may be exempted or provided temporary relief from the activity. The MTW PHA must describe how such households could access the hardship policy and the associated process.

A copy of the MTW PHA’s hardship policy is required to be included in the Appendix of the Annual MTW Plan for purposes of the MTW PHA’s public review and comment period and will not be considered by HUD during the review and approval of the Plan.

3. DESCRIPTION OF ANNUAL REEVALUATION

The MTW PHA must provide an overview as to how the activity will be reevaluated on an annual basis in the Annual MTW Report, mitigating negative impacts and unintended consequences.

4. TRANSITION PERIOD

The MTW PHA must develop a plan and timeline for transitioning households into the activity. If a rent reform activity, the MTW PHA should show how the impact analysis informed this transition period.

3. PROPOSED MTW ACTIVITIES: HUD Approval Requested

Annual MTW REPORT

Section III in the Annual MTW Report will be included and left blank. MTW PHAs should include a placeholder section with the statement that reads: “All proposed MTW activities that were granted approval by HUD are reported in Section IV as ‘Approved Activities’.”

4. APPROVED MTW ACTIVITIES: HUD Approval Previously Granted

All required elements below must be put in the body of the Annual MTW Plan/Report and grouped by each approved MTW activity. For metrics information, MTW PHAs must follow the guidelines from the “Standard HUD Metrics” section of this Form 50900. MTW PHAs must report all applicable Standard HUD Metrics for each activity as assigned by HUD in the Annual MTW Report.

1. IMPLEMENTED ACTIVITIES

The MTW PHA must give the name and unique number of approved MTW activities in the implemented category (see the “Section-by-Section Instructions” for more information on categorizing approved MTW activities) and the following information:

Annual MTW Plan	Annual MTW Report
Plan Year Approved, Implemented, Amended Specify the Plan Year the MTW activity was proposed. Specify the Plan Year the MTW activity was implemented. Provide any Plan Years in which the MTW activity was amended.	Plan Year Approved, Implemented, Amended Specify the Plan Year the MTW activity was proposed. Specify the Plan Year the MTW activity was implemented. Provide any Plan Years in which the MTW activity was amended.
Description/Update Provide a description of the MTW activity. Provide an update on the status of the MTW activity.	Description/Impact/Update Provide a description of the MTW activity and detailed information on its impact during the Plan Year. Provide the applicable Standard HUD Metrics tables with numerical information for baselines, benchmarks and outcomes for the Plan Year. Describe how outcomes compared to baselines and benchmarks. Indicate whether the MTW activity is on schedule. NOTE: For rent reform/public housing term limit activities, describe the number and results of any hardship requests and details regarding the required “Annual Reevaluation” that the MTW PHA put in place when proposing the MTW activity.
Planned Non-Significant Changes Indicate any non-significant changes or modifications to the MTW activity that the MTW PHA plans to pursue during the Plan Year (or state that there are none).	iii. Actual Non-Significant Changes Indicate if the MTW PHA made the planned non-significant changes or modifications to the MTW activity given in the Annual MTW Plan in the Plan Year. Indicate any unplanned non-significant changes or modifications to the MTW activity the MTW PHA made in the Plan Year (or state that there were none).
Planned Changes to Metrics/Data Collection Indicate any changes or modifications to the metrics the MTW PHA plans to pursue during the Plan Year (or state that there are none).	iv. Actual Changes to Metrics/Data Collection Indicate if the MTW PHA made the planned changes or modifications to the metrics given in the Annual MTW Plan in the Plan Year. Indicate any unplanned changes or modifications to the metrics the MTW PHA made in the Plan Year (or state that there were none).
Planned Significant Changes Provide any plans to pursue a significant change to the MTW activity through an Annual MTW Plan amendment in the Plan Year (or state that there are none). NOTE: HUD requires MTW PHAs to re-propose MTW activities that require a “significant change”. Re-proposing an MTW activity requires that it be included in Section (III) of an Annual MTW Plan/Plan amendment with all the associated required elements given in this Form 50900, including the requisite public process. See the “Section-by-Section Instructions” for more information on “significant changes.”	v. Actual Significant Changes Indicate if any significant changes were made to the MTW activity in the Plan Year through an Annual MTW Plan amendment (or state that there were none).
	Challenges in Achieving Benchmarks and Possible Strategies If benchmarks were not achieved or if the MTW activity was determined ineffective (as described in IV.A.ii above), provide a narrative explanation of the challenges and, if possible, identify potential new strategies to make the MTW activity more effective.

B. NOT YET IMPLEMENTED ACTIVITIES

The MTW PHA must give the name and unique number of approved MTW activities in the not yet implemented category (see the “Section-by-Section Instructions” for more information on categorizing approved MTW activities) and the following information:

Annual MTW Plan	Annual MTW Report
Describe the approved MTW activity that was proposed in an Annual MTW Plan, approved by HUD, and not yet implemented. Discuss why the MTW activity was not yet implemented. Specify the Plan Year in which the MTW activity was first approved.	Provide a brief description of the approved MTW activity that was proposed in an Annual MTW Plan, approved by HUD, and not yet implemented. Specify the Plan Year in which the MTW activity was first approved.
Provide an update on the implementation plan for the MTW activity. Provide a timeline associated with this implementation plan. If there are no plans to implement the MTW activity, state that the MTW PHA will move it to the “Closed Out Activities” category in the next Annual MTW Report.	Discuss any actions taken towards the implementation plan for the MTW activity in the Plan Year. Relate these actions to the implementation plan and timeline the MTW PHA provided in the Annual MTW Plan.
Provide an explanation of any non-significant changes or modifications to the MTW activity since it was approved by HUD.

C. ACTIVITIES ON HOLD

The MTW PHA must give the name and unique number of approved MTW activities in the activities on hold category (see the “Section-by-Section Instructions” for more information on categorizing approved MTW activities) and the following information:

Annual MTW Plan	Annual MTW Report
Describe the approved MTW activity that was approved, implemented and that the MTW PHA then stopped implementing (but has plans to reactivate in the future). Describe why the MTW activity was placed on hold. Specify the Plan Year(s) in which the MTW activity was first approved, implemented and placed on hold.	Provide a brief description of the approved MTW activity that was approved, implemented and that the MTW PHA then stopped implementing (but has plans to reactivate in the future). Specify the Plan Year(s) in which the MTW activity was first approved, implemented and placed on hold.
Provide an update on the plan for reactivating the MTW activity. Provide a timeline associated with this reactivation plan. If there are no plans to reactivate the MTW activity, state that the MTW PHA will move it to the “Closed Out Activities” category in the next Annual MTW Report.	Discuss any actions taken towards the plan for reactivating the MTW activity in the Plan Year. Relate these actions to the reactivation plan and timeline the MTW PHA provided in the Annual MTW Plan.
Provide an explanation of any non-significant changes or modifications to the MTW activity since it was approved by HUD.

D. CLOSED OUT ACTIVITIES

The MTW PHA must give the name and unique number of approved MTW activities in the closed out category (see the “Section-by-Section Instructions” for more information on categorizing approved MTW activities) and the following information:

Annual MTW Plan	Annual MTW Report
List the closed out MTW activity. Specify the Plan Year(s) in which the MTW activity was approved, implemented (if applicable) and closed out.	List the closed out MTW activity. Specify the Plan Year(s) in which the MTW activity was approved, implemented (if applicable) and closed out.
Explain why the MTW activity was closed out.	Explain why the MTW activity was closed out.
	In the Plan Year that the MTW activity is closed out, provide the following: Discussion of the final outcome and lessons learned. Description of any statutory exceptions outside of the current MTW flexibilities that might have provided additional benefit to the MTW activity (if applicable). Summary table listing outcomes from each year the MTW activity was implemented (if applicable).

5. PLANNED APPLICATION OF MTW FUNDS

Annual MTW Plan

1. PLANNED APPLICATION OF MTW FUNDS

1. Estimated Sources of MTW Funds

The MTW PHA shall provide the estimated sources and amount of MTW funding by Financial Data Schedule (FDS) line item.

Note: the information collected in this section is to fulfill MTW programmatic reporting requirements and does not replace the MTW PHA’s obligation to annually complete its audited financial statements through HUD’s Financial Data Schedule (FDS).

FDS LINE ITEM NUMBER	FDS LINE ITEM NAME	DOLLAR AMOUNT
70500 (70300+70400)	Total Tenant Revenue	$#
70600	HUD PHA Operating Grants	$#
70610	Capital Grants	$#
70700 (70710+70720+70730+70740+70750)	Total Fee Revenue	$#
71100+72000	Interest Income	$#
71600	Gain or Loss on Sale of Capital Assets	$#
71200+71300+71310+71400+71500	Other Income	$#
70000	Total Revenue	$#

2. Estimated Application of MTW Funds

The MTW PHA shall provide the estimated application of MTW funding in the plan year by Financial Data Schedule (FDS) line item. Only amounts estimated to be spent during the plan year should be identified here; unspent funds that the MTW PHA is not planning on expending during the plan year should not be included in this section.

Note: the information collected in this section is to fulfill MTW programmatic reporting requirements and does not replace the MTW PHA’s obligation to annually complete its audited financial statements through HUD’s Financial Data Schedule.

FDS LINE ITEM NUMBER	FDS LINE ITEM NAME	DOLLAR AMOUNT
91000 (91100+91200+91400+91500+91600+91700+91800+91900)	Total Operating - Administrative	$#
91300+91310+92000	Management Fee Expense	$#
91810	Allocated Overhead	$#
92500 (92100+92200+92300+92400)	Total Tenant Services	$#
93000 (93100+93600+93200+93300+93400+93800)	Total Utilities	$#
93500+93700	Labor	$#
94000 (94100+94200+94300+94500)	Total Ordinary Maintenance	$#
95000 (95100+95200+95300+95500)	Total Protective Services	$#
96100 (96110+96120+96130+96140)	Total Insurance Premiums	$#
96000 (96200+96210+96300+96400+96500+96600+96800)	Total Other General Expenses	$#
96700 (96710+96720+96730)	Total Interest Expense & Amortization Cost	$#
97100+97200	Total Extraordinary Maintenance	$#
97300+97350	HAP + HAP Portability-In	$#
97400	Depreciation Expense	$#
97500+97600+97700+97800	All Other Expense	$#
90000	Total Expenses	$#

Please describe any variance between Estimated Total Revenue and Estimated Total Expenses:

Description or N/A

3. Description of Planned Application of MTW Funding Flexibility

MTW agencies have the flexibility to apply fungibility across three core funding programs’ funding streams – public housing Operating Funds, public housing Capital Funds, and HCV assistance (to include both HAP and Administrative Fees) – hereinafter referred to as “MTW Funding.” The MTW PHA shall provide a thorough narrative of planned activities it plans to undertake using its unspent MTW Funding. Where possible, the MTW PHA may provide metrics to track the outcomes of these programs and/or activities. Activities that use other MTW authorizations in Attachment C and/or D of the Standard MTW Agreement (or analogous section in a successor MTW Agreement) do not need to be described here, as they are already found in Section (III) or Section (IV) of the Annual MTW Plan. The MTW PHA shall also provide a thorough description of how it plans to use MTW funding flexibility to direct funding towards specific housing and/or service programs and/or other MTW activity, as included in an approved MTW Plan.

PLANNED APPLICATION OF MTW FUNDING FLEXIBILITY

Description

(IV.) PLANNED APPLICATION OF PHA UNSPENT OPERATING FUND AND HCV FUNDING

Original Funding Source	Beginning of FY - Unspent Balances	Planned Application of PHA Unspent Funds during FY
HCV HAP*	$	$
HCV Admin Fee	$	$
PH Operating Subsidy	$	$
TOTAL:	$	$

Description of Planned Expenditures of Unspent Operating Fund and HCV Funding

The MTW PHA shall provide a description of planned activities and/or use(s) for unexpended Operating Fund and HCV Funding. The original funding source is defined as the legacy MTW PHA’s appropriated Section 8 and Section 9 funding source(s) (HCV HAP, HCV Admin Fee, and PH Operating Subsidy). The MTW agency receives this information in their Annual Renewal Allocation, which provides a breakdown of the annual obligations for HCV HAP. For HCV Admin Fee, the biannual cash management reconciliation includes the HCV Admin Fee that has been earned at two points during the year; midyear at June 30^th and end-of-year at December 31^st. For the public housing operating fund unspent balance, the MTW PHA may derive their unspent funds by subtracting current assets from current liabilities in the most recent FDS submission. Current assets are the sums of FDS lines 111, 114, 115, 120, 131, 135, 142, 144, and 145. Current liabilities are the sums of FDS line 310 and 343. Table XX below represents the applicable FDS lines with definitions that MTW PHA(s) should utilize to calculate public housing operating fund unspent funds. More information on FDS line items can be found at: https://www.hud.gov/sites/dfiles/PIH/documents/FDSLineDefinitionGuide_vJuly2020.pdf.

Table XX: FDS Line Items Used to Calculate Public Housing Operating Fund Unspent Funds

FDS Line Number	FDS Line Item	Definition
Current Assets
111	Cash-Unrestricted	This FDS line represents cash and cash equivalents in any form available for use to support any activity of the program or project.
114	Cash-Tenant Security Deposits	This FDS line represents cash in the Security Deposit Fund.
115	Cash-Restricted for Payment of Current Liabilities	This line represents restricted cash and cash equivalents that are only to be expended for specified purposes.
120	Total Receivables	This line represents the total of all receivables less the amounts established as allowances for estimated uncollectible amounts.
131	Investments-Unrestricted	This line represents the fair market value of all investments which can be used to support any activity of a program, project, activity, COCC, or entities.
135	Investments-Restricted for Payment of Current Liability	This line represents the fair market value of all investments designated for specific purposes that will be used to liquidate a current liability in the next fiscal year or offset unearned revenue.
142	Prepaid Expenses and Other Assets	This line represents all prepaid expenses. These are not expected to be converted.
144	Inter-program-Due From	This line represents amounts due from other PHA projects, programs, and activities of a temporary nature.
145	Assets Held for Sale	This line item represents assets that the entity expects to sell to qualified applicants. This line item is typically used as part of the homeownership program.
Current Liabilities
310	Total Current Liabilities	This FDS line is the sum of lines 311 through 348 and represents the total of all current liabilities.
343	Current Portion of Long-Term Debt (Capital Projects/Bonds)	This line includes the current portion of debts acquired and debts issued for capital purposes of the PHA/entity.

For HCV funding, the biannual cash management reconciliation for HUD-held reserves includes both HCV and SPV reserves. MTW PHA(s)’ accounting records should include sufficient detail to report on the amount that are HCV versus SPV reserves. Where possible, please identify the planned use, the estimated amount, to which funding source the planned use(s) is attributable, as well as the projected timeline or timeline update.

Note: the information collected in this section is to fulfill MTW programmatic reporting requirements and does not replace the MTW PHA’s obligation to annually complete its audited financial statements through HUD’s Financial Data Schedule.

Description

* Unspent HAP funding should not include amounts recognized as Special Purpose Vouchers reserves.

** HUD’s approval of the MTW Plan does not extend to a PHA’s planned usage of unspent funds amount entered as an agency’s operating reserve. Such recording is to ensure agencies are actively monitoring unspent funding levels and usage(s) to ensure successful outcomes as per the short- and long-term goals detailed in the Plan.

(V). LOCAL ASSET MANGEMENT PLAN

Yes/No

1. Is the MTW PHA allocating costs within statute?

Yes/No

2. Is the MTW PHA implementing a local asset management plan (LAMP)?

Yes/No

3. Has the MTW PHA provide a LAMP in the appendix?

4. If the MTW PHA has provided a LAMP in the appendix, please describe any proposed changes to the LAMP in the Plan Year or state that the MTW PHA does not plan to make any changes in the Plan Year.

Description

(VI). RENTAL ASSISTANCE DEMONSTRATION (RAD) PARTICIPATION

1. Description of RAD Participation

The MTW PHA shall provide a brief description of its participation in RAD. This description must include the proposed and/or planned number of units to be converted under RAD, under which component the conversion(s) will occur, and approximate timing of major milestones. The MTW PHA should also give the planned/actual submission dates of all RAD Significant Amendments. Dates of any approved RAD Significant Amendments should also be provided.

RENTAL ASSISTANCE DEMONSTRATION (RAD) PARTICIPATION

Description

Yes/No

2. Has the MTW PHA submitted a RAD Significant Amendment in the appendix? A RAD Significant Amendment should only be included if it is a new or amended version that requires HUD approval.

3. If the MTW PHA has provided a RAD Significant Amendment in the appendix, please state whether it is the first RAD Significant Amendment submitted or describe any proposed changes from the prior RAD Significant Amendment?

Description

(V) PLANNED APPLICATION OF MTW FUNDS

Annual MTW REPORT

1. FINANCIAL REPORTING

1. Available MTW Funds in the Plan Year

The MTW PHA shall submit unaudited and audited information in the prescribed Financial Data Schedule (FDS) format through the Financial Assessment System – PHA (FASPHA), or its successor system.

2. Expenditures of MTW Funds in the Plan Year

The MTW PHA shall submit unaudited and audited information in the prescribed FDS format through the FASPHA, or its successor system.

3. Describe Application of MTW Funding Flexibility

The MTW PHA shall provide a thorough narrative of actual activities that use only the MTW funding flexibility. Where possible, the MTW PHA may provide metrics to track the outcomes of these programs and/or activities. Activities that use other MTW authorizations in Attachment C and/or D of the Standard MTW Agreement (or analogous section in a successor MTW Agreement) do not need to be described here, as they are already found in Section (IV) of the Annual MTW Report. The MTW PHA shall also provide a thorough description of how it used MTW funding flexibility to direct funding towards specific housing and/or service programs and/or other MTW activity, as included in an approved MTW Plan.

APPLICATION OF “MTW FUNDING” FLEXIBILITY

Description

2. LOCAL ASSET MANGEMENT PLAN

Yes/No

1. Did the MTW PHA allocate costs within statute in the Plan Year?

Yes/No

2. Did the MTW PHA implement a local asset management plan (LAMP) in the Plan Year?

Yes/No

3. Did the MTW PHA provide a LAMP in the appendix?

4. If the MTW PHA has provided a LAMP in the appendix, please provide a brief update on implementation of the LAMP. Please provide any actual changes (which must be detailed in an approved Annual MTW Plan/Plan amendment) or state that the MTW PHA did not make any changes in the Plan Year.

Description

6. ADMINISTRATIVE

Annual MTW Plan	Annual MTW Report
A. BOARD RESOLUTION AND CERTIFICATIONS OF COMPLIANCE The MTW PHA shall provide a resolution signed by the Board of Commissioners (or other authorized MTW PHA governing body) adopting the Annual MTW Plan and the Annual MTW Plan Certifications of Compliance (as it appears in this Form 50900). A signed version of the Annual MTW Plan Certifications of Compliance must also be included.	A. REVIEWS, AUDITS AND INSPECTIONS The MTW PHA shall provide a general description of any HUD reviews, audits and/or physical inspection issues that require the MTW PHA to take action in order to address the issue.
B. DOCUMENTATION OF PUBLIC PROCESS The beginning and end dates of when the Annual MTW Plan was made available for public review and the dates, location and number of attendees of public hearings must be provided. HUD reserves the right to request additional information to verify the MTW PHA has complied with public process requirements in the Standard MTW Agreement (or successor MTW Agreement).	B. EVALUATION RESULTS The MTW PHA shall provide a description of the results of the latest MTW PHA-directed evaluation (or state that there are none).
C. PLANNED AND ONGOING EVALUATIONS The MTW PHA shall provide a description of any planned or ongoing MTW PHA-directed evaluations of the MTW demonstration and/or of any specific MTW activities (or state that there are none).	C. MTW STATUTORY REQUIREMENT CERTIFICATION The MTW PHA shall provide a certification that the MTW PHA has met the three MTW statutory requirements in the Plan Year of: (1) ensuring that at least 75% of households assisted by the MTW PHA are very low-income, (2) continuing to assist substantially the same total number of households as would have been assisted had the MTW PHA not participated in the MTW demonstration, and (3) maintaining a comparable mix of households (by family size) served as would have been served had the MTW PHA not participated in the MTW demonstration.
D. LOBBYING DISCLOSURES The MTW PHA shall provide signed copies of the Disclosure of Lobbying Activities (SF-LLL) and the related Certification of Payments (HUD-50071).	D. MTW ENERGY PERFORMANCE CONTRACT (EPC) FLEXIBILITY DATA Some MTW PHAs possess flexibility with regard to EPCs in the Standard MTW Agreement. MTW PHAs that possess and utilize this flexibility should here report the data as specified in the MTW PHA’s Standard MTW Agreement (or successor MTW Agreement). If the MTW PHA does not possess and/or utilize such flexibility, this section should be marked not applicable.

CERTIFICATIONS OF COMPLIANCE

U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT

OFFICE OF PUBLIC AND INDIAN HOUSING

Certifications of Compliance with Regulations:

Board Resolution to Accompany the Annual Moving to Work Plan

Acting on behalf of the Board of Commissioners of the Moving to Work Public Housing Agency (MTW PHA) listed below, as its Chairman or other authorized MTW PHA official if there is no Board of Commissioners, I approve the submission of the Annual Moving to Work Plan for the MTW PHA Plan Year beginning (DD/MM/YYYY), hereinafter referred to as "the Plan", of which this document is a part and make the following certifications and agreements with the Department of Housing and Urban Development (HUD) in connection with the submission of the Plan and implementation thereof:

1. The MTW PHA published a notice that a hearing would be held, that the Plan and all information relevant to the public hearing was available for public inspection for at least 30 days, that there were no less than 15 days between the public hearing and the approval of the Plan by the Board of Commissioners, and that the MTW PHA conducted a public hearing to discuss the Plan and invited public comment.

2. The MTW PHA took into consideration public and resident comments (including those of its Resident Advisory Board or Boards) before approval of the Plan by the Board of Commissioners or Board of Directors in order to incorporate any public comments into the Annual MTW Plan.

3. The MTW PHA certifies that the Board of Directors has reviewed and approved the budget for the Capital Fund Program grants contained in the Capital Fund Program Annual Statement/Performance and Evaluation Report, form HUD-50075.1 (or successor form as required by HUD).

4. The MTW PHA will carry out the Plan in conformity with Title VI of the Civil Rights Act of 1964, the Fair Housing Act, section 504 of the Rehabilitation Act of 1973, and title II of the Americans with Disabilities Act of 1990.

5. The Plan is consistent with the applicable comprehensive housing affordability strategy (or any plan incorporating such strategy) for the jurisdiction in which the PHA is located.

6. The Plan contains a certification by the appropriate state or local officials that the Plan is consistent with the applicable Consolidated Plan.

7. The MTW PHA will affirmatively further fair housing by fulfilling the requirements set out in HUD regulations found at Title 24 of the Code of Federal Regulations, including regulations in place at the time of this certification, and any subsequently promulgated regulations governing the obligation to affirmatively further fair housing. The MTW PHA is always responsible for understanding and implementing the requirements of HUD regulations and policies, and has a continuing obligation to affirmatively further fair housing in compliance with the 1968 Fair Housing Act, the Housing and Community Development Act of 1974, The Cranston-Gonzalez National Affordable Housing Act, and the Quality Housing and Work Responsibility Act of 1998. (42 U.S.C. 3608, 5304(b)(2), 5306(d)(7)(B), 12705(b)(15), and 1437C–1(d)(16)). The MTW PHA will affirmatively further fair housing by fulfilling the requirements at 24 CFR 903.7(o) and 24 CFR 903.15(d), which means that it will take meaningful actions to further the goals identified in the Assessment of Fair Housing (AFH) conducted in accordance with the requirements of 24 CFR 5.150 through 5.180, that it will take no action that is materially inconsistent with its obligation to affirmatively further fair housing, and that it will address fair housing issues and contributing factors in its programs, in accordance with 24 CFR 903.7(o)(3). Until such time as the MTW PHA is required to submit an AFH, and that AFH has been accepted by HUD, the MTW PHA will address impediments to fair housing choice identified in the Analysis of Impediments to fair housing choice associated with any applicable Consolidated or Annual Action Plan under 24 CFR Part 91.

8. The MTW PHA will comply with the prohibitions against discrimination on the basis of age pursuant to the Age Discrimination Act of 1975 and HUD’s implementing regulations at 24 C.F.R. Part 146.

9. In accordance with 24 CFR 5.105(a)(2), HUD’s Equal Access Rule, the MTW PHA will not make a determination of eligibility for housing based on sexual orientation, gender identity, or marital status.

10. The MTW PHA will comply with the Architectural Barriers Act of 1968 and 24 CFR Part 41, Policies and Procedures for the Enforcement of Standards and Requirements for Accessibility by the Physically Handicapped.

11.  The MTW PHA will comply with the requirements of section 3 of the Housing and Urban Development Act of 1968, Employment Opportunities for Low-or Very-Low Income Persons, and with its implementing regulation at 24 CFR Part 75.

12. The MTW PHA will comply with requirements with regard to a drug free workplace required by 24 CFR Part 24, Subpart F.

13. The MTW PHA will comply with requirements with regard to compliance with restrictions on lobbying required by 24 CFR Part 87, together with disclosure forms if required by this Part, and with restrictions on payments to influence Federal Transactions, in accordance with the Byrd Amendment and implementing regulations at 49 CFR Part 24.

14. The MTW PHA will comply with acquisition and relocation requirements of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 and implementing regulations at 49 CFR Part 24 as applicable.

15. The MTW PHA will take appropriate affirmative action to award contracts to minority and women's business enterprises under 24 CFR 5.105(a).

16. The MTW PHA will provide HUD or the responsible entity any documentation needed to carry out its review under the National Environmental Policy Act and other related authorities in accordance with 24 CFR Part 58. Regardless of who acts as the responsible entity, the MTW PHA will maintain documentation that verifies compliance with environmental requirements pursuant to 24 Part 58 and 24 CFR Part 50 and will make this documentation available to HUD upon its request.

17. With respect to public housing and applicable local, non-traditional development the MTW PHA will comply with Davis-Bacon or HUD determined wage rate requirements under section 12 of the United States Housing Act of 1937 and the Contract Work Hours and Safety Standards Act.

18. The MTW PHA will keep records in accordance with 24 CFR 85.20 and facilitate an effective audit to determine compliance with program requirements.

19. The MTW PHA will comply with the Lead-Based Paint Poisoning Prevention Act and 24 CFR Part 35.

20. The MTW PHA will comply with the policies, guidelines, and requirements of 2 CFR Part 225 (Cost Principles for State, Local and Indian Tribal Governments) and 2 CFR Part 200.

21. The MTW PHA must fulfill its responsibilities to comply with and sure enforcement of Housing Quality Standards, as defined in 24 CFR Part 982 or as approved by HUD, for any Housing Choice Voucher units under administration.

22. The MTW PHA will undertake only activities and programs covered by the Plan in a manner consistent with its Plan and will utilize covered grant funds only for activities that are approvable under the Moving to Work Agreement and Statement of Authorizations and included in its Plan.

23. All attachments to the Plan have been and will continue to be available at all times and all locations that the Plan is available for public inspection. All required supporting documents have been made available for public inspection along with the Plan and additional requirements at the primary business office of the PHA and at all other times and locations identified by the MTW PHA in its Plan and will continue to be made available at least at the primary business office of the MTW PHA.

_________________________________________ _________________________________________

MTW PHA NAME MTW PHA NUMBER/HA CODE

I/We, the undersigned, certify under penalty of perjury that the information provided above is true and correct. 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. (18 U.S.C. §§ 287, 1001, 1010, 1012; 31 U.S.C. §3729, 3802).

_________________________________________ _________________________________________

NAME OF AUTHORIZED OFFICIAL TITLE

_________________________________________ _________________________________________

SIGNATURE DATE

* Must be signed by either the Chair or Secretary of the Board of the MTW PHA's legislative body. This certification cannot be signed by an employee unless authorized by the MTW PHA Board to do so. If this document is not signed by the Chair or Secretary, documentation such as the by-laws or authorizing board resolution must accompany this certification.

STANDARD HUD METRICS

For all activities in Section (III) Proposed Activities and activities in Section (IV) Approved Activities in the "Implemented" category, the MTW PHA must use all of the applicable Standard HUD Metrics listed below. Standard HUD Metrics must be reported in the table format provided in order to allow analysis and aggregation across MTW PHAs for similar activities.

For Standard HUD Metrics that are different from the metrics the MTW PHA had been reporting on for an implemented MTW activity, the MTW PHA may set a baseline prior to when the MTW activity began (through historical records or extrapolation from available data). If such information is not available, the MTW PHA may set the baseline in the Annual MTW Report where the Standard HUD Metric is first presented. If one of the Standard HUD Metrics had not been used in previous Annual MTW Reports, the MTW PHA must begin tracking the MTW activity using the Standard HUD Metrics during the current Plan Year.

MTW PHAs should show the component variables that comprise figures (for example, in showing a "Total Cost," an MTW PHA would show the cost per transaction and number of transactions).

MTW PHAs have the flexibility to report on agency developed and previously established metrics in addition to the required Standard HUD Metrics.

COST EFFECTIVENESS

When citing the statutory objective to “reduce cost and achieve greater cost effectiveness in federal expenditures,” include all of the following metrics that apply:

CE #1: Agency Cost Savings

Unit of Measurement	Baseline	Benchmark	Outcome	Benchmark Achieved?
Total cost of task in dollars (decrease).	Cost of task prior to implementation of the activity (in dollars).	Expected cost of task after implementation of the activity (in dollars).	Actual cost of task after implementation of the activity (in dollars).	Whether the outcome meets or exceeds the benchmark.

CE #2: Staff Time Savings

Unit of Measurement	Baseline	Benchmark	Outcome	Benchmark Achieved?
Total time to complete the task in staff hours (decrease).	Total amount of staff time dedicated to the task prior to implementation of the activity (in hours).	Expected amount of total staff time dedicated to the task after implementation of the activity (in hours).	Actual amount of total staff time dedicated to the task after implementation of the activity (in hours).	Whether the outcome meets or exceeds the benchmark.

CE #3: Decrease in Error Rate of Task Execution

Unit of Measurement	Baseline	Benchmark	Outcome	Benchmark Achieved?
Average error rate in completing a task as a percentage (decrease).	Average error rate of task prior to implementation of the activity (percentage).	Expected average error rate of task after implementation of the activity (percentage).	Actual average error rate of task after implementation of the activity (percentage).	Whether the outcome meets or exceeds the benchmark.

CE #4: Increase in Resources Leveraged

Unit of Measurement	Baseline	Benchmark	Outcome	Benchmark Achieved?
Amount of funds leveraged in dollars (increase).	Amount leveraged prior to implementation of the activity (in dollars). This number may be zero.	Expected amount leveraged after implementation of the activity (in dollars).	Actual amount leveraged after implementation of the activity (in dollars).	Whether the outcome meets or exceeds the benchmark.

CE #5: Increase in Agency Rental Revenue

Unit of Measurement	Baseline	Benchmark	Outcome	Benchmark Achieved?
Total Household contributions towards housing assistance (increase).	Household contributions prior to implementation of the activity (in dollars).	Expected household contributions after implementation of the activity (in dollars).	Actual household contributions after implementation of the activity (in dollars).	Whether the outcome meets or exceeds the benchmark.

CE #6: Reducing Per Unit Subsidy Costs for Participating Households

Unit of Measurement	Baseline	Benchmark	Outcome	Benchmark Achieved?
Average amount of Section 8 and/or 9 subsidy (or local, non-traditional subsidy) per household affected by this policy in dollars (decrease).	Average subsidy per household affected by this policy prior to implementation of the activity (in dollars).	Expected average subsidy per household affected by this policy after implementation of the activity (in dollars).	Actual average subsidy per household affected by this policy after implementation of the activity (in dollars).	Whether the outcome meets or exceeds the benchmark.

SELF SUFFICIENCY

When citing the statutory objective to “give incentives to families…whose heads of household are either working, seeking work, or are participating in job training educational or other programs to assist in obtaining employment and becoming economically self-sufficient,” include all of the following metrics that apply:

SS #1: Increase in Household Income

Unit of Measurement	Baseline	Benchmark	Outcome	Benchmark Achieved?
Average earned income of households affected by this policy in dollars (increase).	Average earned income of households affected by this policy prior to implementation of the activity (in dollars).	Expected average earned income of households affected by this policy prior to implementation of the activity (in dollars).	Actual average earned income of households affected by this policy prior to implementation (in dollars).	Whether the outcome meets or exceeds the benchmark.

SS #2: Increase in Household Savings

Unit of Measurement	Baseline	Benchmark	Outcome	Benchmark Achieved?
Average amount of savings/escrow of households affected by this policy in dollars (increase).	Average savings/escrow amount of households affected by this policy prior to implementation of the activity (in dollars). This number may be zero.	Expected average savings/escrow amount of households affected by this policy after implementation of the activity (in dollars).	Actual average savings/escrow amount of households affected by this policy after implementation of the activity (in dollars).	Whether the outcome meets or exceeds the benchmark.

SS#3: Increase in Positive Outcomes in Employment Status

Unit of Measurement	Baseline	Benchmark	Outcome	Benchmark Achieved?
Report the following information separately for each category: (1) Employed Full- Time (2) Employed Part- Time (3) Enrolled in an Educational Program	Head(s) of households in <<category name>> prior to implementation of the activity (number). This number may be zero.	Expected head(s) of work-able households in <<category name>> after implementation of the activity (number).	Actual head(s) of work-able households in <<category name>> after implementation of the activity (number).	Whether the outcome meets or exceeds the benchmark.
(4) Enrolled in Job Training Program (5) Unemployed (6) Other	Percentage of total work-able households in <<category name>> prior to implementation of activity (percent). This number may be zero.	Expected percentage of total work-able households in <<category name>> after implementation of the activity (percent).	Actual percentage of total work-able households in <<category name>> after implementation of the activity (percent).	Whether the outcome meets or exceeds the benchmark.

SS #4: Households Removed from Temporary Assistance for Needy Families (TANF)

Unit of Measurement	Baseline	Benchmark	Outcome	Benchmark Achieved?
Number of households receiving TANF assistance (decrease).	Households receiving TANF prior to implementation of the activity (number).	Expected number of households receiving TANF after implementation of the activity (number).	Actual households receiving TANF after implementation of the activity (number).	Whether the outcome meets or exceeds the benchmark.

SS #5: Households Assisted by Services that Increase Self Sufficiency

Unit of Measurement	Baseline	Benchmark	Outcome	Benchmark Achieved?
Number of households receiving services aimed to increase self sufficiency (increase).	Households receiving self sufficiency services prior to implementation of the activity (number).	Expected number of households receiving self sufficiency services after implementation of the activity (number).	Actual number of households receiving self sufficiency services after implementation of the activity (number).	Whether the outcome meets or exceeds the benchmark.

SS #6: Reducing Per Unit Subsidy Costs for Participating Households

Unit of Measurement	Baseline	Benchmark	Outcome	Benchmark Achieved?
Average amount of Section 8 and/or 9 subsidy (or local, non-traditional subsidy) per household affected by this policy in dollars (decrease).	Average subsidy per household affected by this policy prior to implementation of the activity (in dollars).	Expected average subsidy per household affected by this policy after implementation of the activity (in dollars).	Actual average subsidy per household affected by this policy after implementation of the activity (in dollars).	Whether the outcome meets or exceeds the benchmark.

SS #7: Increase in Agency Rental Revenue

Unit of Measurement	Baseline	Benchmark	Outcome	Benchmark Achieved?
Total Household contributions towards housing assistance (increase).	Household contributions prior to implementation of the activity (in dollars).	Expected household contributions after implementation of the activity (in dollars).	Actual household contributions after implementation of the activity (in dollars).	Whether the outcome meets or exceeds the benchmark.

SS #8: Households Transitioned to Self Sufficiency

Unit of Measurement	Baseline	Benchmark	Outcome	Benchmark Achieved?
Number of households transitioned to self-sufficiency (increase). The PHA may create one or more definitions for "self-sufficiency" to use for this metric. Each time the PHA uses this metric, the "Outcome" number should also be provided in Section (II) Operating Information in the space provided.	Households transitioned to self-sufficiency (<<PHA definition of self-sufficiency>>) prior to implementation of the activity (number). This number may be zero.	Expected households transitioned to self-sufficiency (<<PHA definition of self-sufficiency>>) after implementation of the activity (number).	Actual households transitioned to self-sufficiency (<<PHA definition of self-sufficiency>>) after implementation of the activity (number).	Whether the outcome meets or exceeds the benchmark.

HOUSING CHOICE

When citing the statutory objective to “increase housing choices for low-income families,” include all of the following metrics that apply:

HC #1: Additional Units of Housing Made Available

Unit of Measurement	Baseline	Benchmark	Outcome	Benchmark Achieved?
Number of new housing units made available for households at or below 80% AMI as a result of the activity (increase). If units reach a specific type of household, give that type in this box.	Housing units of this type prior to implementation of the activity (number). This number may be zero.	Expected housing units of this type after implementation of the activity (number).	Actual housing units of this type after implementation of the activity (number).	Whether the outcome meets or exceeds the benchmark.

HC #2: Units of Housing Preserved

Unit of Measurement	Baseline	Benchmark	Outcome	Benchmark Achieved?
Number of housing units preserved for households at or below 80% AMI that would otherwise not be available (increase). If units reach a specific type of household, give that type in this box.	Housing units preserved prior to implementation of the activity (number).	Expected housing units preserved after implementation of the activity (number).	Actual housing units preserved after implementation of the activity (number).	Whether the outcome meets or exceeds the benchmark.

HC #3: Decrease in Wait List Time

Unit of Measurement	Baseline	Benchmark	Outcome	Benchmark Achieved?
Average applicant time on wait list in months (decrease).	Average applicant time on wait list prior to implementation of the activity (in months).	Expected average applicant time on wait list after implementation of the activity (in months).	Actual average applicant time on wait list after implementation of the activity (in months).	Whether the outcome meets or exceeds the benchmark.

HC #4: Displacement Prevention

Unit of Measurement	Baseline	Benchmark	Outcome	Benchmark Achieved?
Number of households at or below 80% AMI that would lose assistance or need to move (decrease). If units reach a specific type of household, give that type in this box.	Households losing assistance/moving prior to implementation of the activity (number).	Expected households losing assistance/moving after implementation of the activity (number).	Actual households losing assistance/moving after implementation of the activity (number).	Whether the outcome meets or exceeds the benchmark.

HC #5: Increase in Resident Mobility

Unit of Measurement	Baseline	Benchmark	Outcome	Benchmark Achieved?
Number of households able to move to a better unit and/or neighborhood of opportunity as a result of the activity (increase).	Households able to move to a better unit and/or neighborhood of opportunity prior to implementation of the activity (number). This number may be zero.	Expected households able to move to a better unit and/or neighborhood of opportunity after implementation of the activity (number).	Actual increase in households able to move to a better unit and/or neighborhood of opportunity after implementation of the activity (number).	Whether the outcome meets or exceeds the benchmark.

HC #6: Increase in Homeownership Opportunities

Unit of Measurement	Baseline	Benchmark	Outcome	Benchmark Achieved?
Number of households that purchased a home as a result of the activity (increase).	Number of households that purchased a home prior to implementation of the activity (number). This number may be zero.	Expected number of households that purchased a home after implementation of the activity (number).	Actual number of households that purchased a home after implementation of the activity (number).	Whether the outcome meets or exceeds the benchmark.

HC #7: Households Assisted by Services that Increase Housing Choice

Unit of Measurement	Baseline	Benchmark	Outcome	Benchmark Achieved?
Number of households receiving services aimed to increase housing choice (increase).	Households receiving this type of service prior to implementation of the activity (number). This number may be zero.	Expected number of households receiving these services after implementation of the activity (number).	Actual number of households receiving these services after implementation of the activity (number).	Whether the outcome meets or exceeds the benchmark.

Privacy Act Statement. This statement is provided pursuant to the Privacy Act of 1974, 5 USC § 552a. The authority for collecting personally identifiable information (PII) in the Regulatory Consistency Communication Board (RCCB) Electronic Feedback Form is based in Section 313 of Public Law 112-95.

HUD FORM 50900: Instructions 3