Form Hud 50058 Mtw – Fill Out and Use This PDF

The HUD-50058 MTW form is an essential document for participants and administrators of the Moving to Work (MTW) program, which encompasses Public Housing and Section 8 programs. Managed by the U.S. Department of Housing and Urban Development, this form helps in collecting vital information for managing and monitoring HUD-assisted housing programs, ensuring compliance with program requirements, and planning for future housing needs. For an easy way to fulfill your HUD reporting requirements, click the button below to start filling out your form.

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Form Hud 50058 Mtw PDF Details

The HUD-50058 MTW form, a critical document for families participating in the Moving to Work (MTW) Public Housing and Section 8 programs, serves multiple purposes including monitoring compliance, gathering demographic data, detecting fraud, and planning for housing needs. Endorsed by the U.S. Department of Housing and Urban Development's Office of Public and Indian Housing, this document requires accurate and detailed reporting from housing agencies to assist in the effective management of HUD-assisted housing programs. The form, with its structured fields, captures essential information ranging from personal details of household members to their participation in self-sufficiency programs. Instructions for its completion are detailed in the accompanying instruction booklet, emphasizing the importance of providing complete and accurate information. Each section of the form plays a vital role in ensuring that the needs of various groups, including persons with disabilities, are met, while also ensuring adherence to regulations governing eligibility and assistance. The document, periodically updated to reflect current regulations and requirements, embodies the ongoing commitment to addressing the housing needs of special populations and ensuring the integrity of the housing assistance programs.

Question	Answer
Form Name	Form Hud 50058 Mtw
Form Length	20 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	5 min
Other names	yyyy, MTW, 2001, Homeownership

Form Preview Example

OMB Approval Number 2577-0083 (expires 6/30/2013)

U.S. Department of Housing and Urban Development

Office of Public and Indian Housing

MTW Family Report

Form HUD-50058 MTW, Family Report, applies to Moving to Work Public Housing and Section 8 programs.

Additional instructions are contained in the Form HUD-50058 MTW Instruction Booklet.

Previous editions are obsolete

form HUD-50058 MTW (1/2001)

Public reporting burden for this collection of information is estimated to average 30 minutes per response in the first year, and 15 minutes per response in subsequent years. This estimate includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This agency may not collect this information, and you are not required to complete this form, unless it displays a currently valid OMB control number.

Send the data to the electronic address required by HUD. Questions? Phone 1-800-FON-MTCS (1-800-366-6827) or go to the MTCS Web Site at http://www.hud.gov/pih/systems/mtcs/pihmtcs.html.

Each affected agency must submit information to assist HUD in managing and monitoring HUD assisted housing programs, to protect the Government’s interest and to verify the accuracy of the information received. HUD will use the information to: (1) monitor program participants’ compliance with requirements, (2) provide demographic information describing tenants’ characteristics, (3) participate in income matching, to detect fraud, and (4) plan for future use of the housing inventory with emphasis on the housing needs of special groups. This collection is authorized by the U .S. Housing Act of 1937 (42 U.S.C. 1437 et seq.), Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d), the Fair Housing Act (42 U.S.C. 3601-19), and by the Omnibus Consolidated Rescissions and Appropriations Act of 1996 (42 U.S.C. 1437f).

Sensitive Information: The information on these forms is sensitive and is protected by the Privacy Act. Keep the forms locked and confidential.

Acronyms
FSS	=	Family Self-Sufficiency program
HAP	=	Housing Assistance Payment
HQS	=	Housing Quality Standards
HUD	=	U.S. Department of Housing & Urban Development
INS	=	U.S. Immigration and Naturalization Services
OMB	=	U.S. Office of Management and Budget
PHA	=	Public Housing Agency
SSA	=	Social Security Administration
SSI	=	Supplemental Security Income
SSN	=	Social Security Number
TANF	=	Tenant Assistance for Needy Families
TIN	=	Taxpayer Identification Number
TTP	=	Total Tenant Payment
MTW	=	Moving to Work

Major Definitions (refer to the Form HUD-50058 MTW Instruction Booklet for a more detailed definition of each field on the Form):

Disabilities: 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, or (c) a developmental disability as defined in Section 102 of the Developmental Disabilities Assistance and Bill of Rights Act. Note: Include persons who have the acquired immune deficiency syndrome (AIDS) or any condition that arises from the etiologic agent for AIDS.

Effective Date of Action: Date the reported action becomes effective. The effective date cannot be earlier than the date of admission to the program.

Head of household: The one adult member of the household, designated by the family or by PHA policy as the head of household, who is wholly or partly responsible for the rent payment.

Mixed Family: A family that contains some members that are eligible for assistance and some members that are ineligible for assistance. This family may be subject to prorated rent under the Noncitizens Rule.

Portability: Renting a dwelling unit with Section 8 assistance outside the jurisdiction of the initial PHA.

Form Conventions:

1.All fields that require the entry of a date must include the 4-digit year. Enter the date in a standard format (i.e., "mm/ dd/yyyy", "mm/yyyy"). Enter the year in its entirety.

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

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

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

5.Reserved: HUD may have future directions about how to use these lines. Reserved lines are placeholders for future changes.

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

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

Previous editions are obsolete

form HUD-50058 MTW (1/2001)

Head of household name

Social Security Number

Date modified (mm/dd/yyyy)

MTW Family Report

U.S. Department of Housing and Urban Development

OMB Approval Number 2577-0083

Office of Public and Indian Housing

Expires 1/31/2007

MTW Agency

1a.

Agency name

1a.

1b.

PHA code

1b.

1c.

Program

P = Public Housing

PR = Project-Based Assistance

1c.

T = Tenant-Based Assistance

1d.

Project number (Public Housing only)

Suffix:

1d.

1e.

Building number (Public Housing only)

1e.

1f.

Building entrance number (Public Housing only)

1f.

1g.

Unit number (Public Housing only)

1g.

MTW Action

2a.

Type of action

2a.

1 = New Admission

6 = End Participation

11 = Expiration of Voucher Equivalent

2 = Annual Reexamination

7 = Other Change of Unit

12 = Reserved

3 = Interim Reexamination

8 = FSS/MTW Self-Sufficiency Only

13 = Annual HQS Inspection Only

4 = Portability Move-in

9 = Annual Reexamination Searching

14 = Historical Adjustment

5 = Portability Move-out

10 = Issuance of Voucher Equivalent

15 = Void

2b.

Effective date (mm/dd/yyyy) of action

2b.

2c.

Correction?

(Y or N)

2c.

2d. If correction: (check primary reason)

Family income correction Family correction (non-income)

PHA income correction

PHA correction (non-income)

2e.	Date correction transmitted (mm/dd/yyyy)			2e.

2f.	Repayment agreement?	(Y or N)		2f.

2g.	Monthly amount of repayment		$	2g.

2h.	Date (mm/dd/yyyy) of admission to program			2h.

2i.	Projected effective date (mm/dd/yyyy) of next reexamination			2i.

2j.	Date (mm/dd/yyyy) of admission to Moving to Work program			2k.

2k. FSS participation now or in last year? (Y or N)				2k.

2m. MTW self-sufficiency program participation now or in last year? (Y or N)				2m.

2n.	Reserved

2p.	Use if instructed by HUD			2p.
2q.	PHA use only			2q.

2r.	PHA use only			2r.

2s.	PHA use only			2s.
2t.	PHA use only			2t.

2u.	PHA use only			2u.

Previous editions are obsolete

form HUD-50058 MTW (1/2001)

Head of household name

Social Security Number

Date modified (mm/dd/yyyy)

	Page Heading
Head of	On every page, enter the head of household’s last name (line 3b), first name (line 3c) and middle initial (line 3d).
household	Use this field to identify the head of household if the pages of the Form separate.
name:
Social Security	On every page, enter the head of household’s Social Security Number (line 3n). Use this field to identify the head of
Number:	household if the pages of the Form separate.
Date modified	On every page, enter the date the PHA representative fills out the Form or modifies any Form page.
(mm/dd/yyyy):
1:	MTW Agency
Line 1a:	Name of the Public Housing Agency (PHA) that completes the family’s Form HUD-50058 MTW.
Line 1b:	Five-character code composed of the 2-letter postal state code and 3-digit PHA number. The state code indicates
	the location of the reporting PHA and the number identifies each PHA within a particular state.
Note:	For help obtaining the PHA’s identification number, contact the appropriate HUD field office, the HA Profiles Web
	Site within PIC or the MTCS Hotline at 1-800-FON-MTCS.
Line 1c:	Using the codes provided, indicate the housing assistance program in which the family participates.
Line 1d:	Public Housing only. The project number is composed of the 2-letter project state code, 3-digit PHA number, 3-
	digit project number, and 3-digit suffix (if applicable).
Line 1e:	Public Housing only. Six-character code to capture the tenant’s building number.
Line 1f:	Public Housing only. Three-character code to capture the building’s entrance number.
Line 1g:	Public Housing only. Ten-character code to capture the PHA designated tenant unit number.
2:	MTW Action
Line 2a:	Use the codes provided to report the family’s type of action.
Line 2b:	Date the reported action becomes effective.
Note:	The effective date cannot be earlier than the date of admission to the program (line 2h).
Line 2c:	Allows PHAs to correct fields previously transmitted in error.
Note:	Use a correction for a minor change to a previously submitted record.
Line 2d:	Indicate the primary reason for the correction record.
Line 2e:	The actual date that the PHA completes the correction and transmits the corrected record.
Line 2f:	Indicate if the tenant has entered into a repayment agreement because the tenant previously underreported or
	misreported income.
Line 2g:	Per the repayment agreement, the amount the tenant pays each month.
Line 2h:	Date the PHA initially admitted the family into the regular (non-MTW) version of the program reported in line 1c.

Line 2i:	The projected effective date of the family’s next reexamination.
Line 2j:	Date the PHA admitted the family to the Moving to Work program.
Line 2k:	Indicate if the family currently participates or participated in the Family Self-Sufficiency program in the past year.
Line 2m:	Indicate if the family currently participants or participated in an MTW self-sufficiency program in the past year.
Line 2n:	Reserved.
Line 2p:	HUD may instruct a particular PHA to use this line. If there are not instructions to use these lines, leave them blank.
Line 2q-2u:	PHAs may use these lines for any information they wish to collect.
Note:	HUD encourages PHAs to use lines 2q through 2u for local initiatives.

Previous editions are obsolete

i i

formHUD-50058 MTW (1/2001)

Head of household name

Social Security Number

Date modified (mm/dd/yyyy)

MTW Household

3a.

Head of

3b.

Last Name & Sr, Jr. etc.

3c. First name

3d. MI

3e. Date of birth

3f. Age on effective

Household

date of action

Member

3g.

Sex

3h. Relation

3i.

Citizenship

3j.

Disability (Y/N)

3k. Race

3m. Ethnicity

number

3n.

Social Security Number

3p. Alien Registration Number

3q. Meeting community service requirement? (Public Housing

A-

only)

3r.

Total years of school (0-25)

3a.

Member

3b.

Last Name & Sr, Jr. etc.

3c. First name

3d. MI

3e. Date of birth

3f. Age on effective

number

date of action

3g.

Sex

3h. Relation

3i.

Citizenship

3j.

Disability (Y/N)

3k. Race

3m. Ethnicity

3n.

Social Security Number

3p. Alien Registration Number

3q. Meeting community service requirement? (Public Housing only)

A-

3r. Total years of school (0-25)

3a. Member number 03

3b.

Last Name & Sr, Jr. etc.

3c. First name

3d. MI

3e. Date of birth

3f. Age on effective

date of action

3g.

Sex

3h. Relation

3i.

Citizenship

3j. Disability (Y/N)

3k. Race

3m. Ethnicity

3n.

Social Security Number

3p. Alien Registration Number

3q. Meeting community service requirement? (Public Housing only)

A-

3r.

Total years of school (0-25)

3a. Member number 04

3b.

Last Name & Sr, Jr. etc.

3c. First name

3d. MI

3e. Date of birth

3f. Age on effective

date of action

3g.

Sex

3h. Relation

3i.

Citizenship

3j. Disability (Y/N)

3k. Race

3m. Ethnicity

3n.

Social Security Number

3p. Alien Registration Number

3q. Meeting community service requirement? (Public Housing only)

A-

3r.

Total years of school (0-25)

3a. Member number 05

3b.

Last Name & Sr, Jr. etc.

3c. First name

3d. MI

3e. Date of birth

3f. Age on effective

date of action

3g.

Sex

3h. Relation

3i.

Citizenship

3j. Disability (Y/N)

3k. Race

3m. Ethnicity

3n.

Social Security Number

3p. Alien Registration Number

3q. Meeting community service requirement? (Public Housing only)

A-

3r.

Total years of school (0-25)

Codes:

3h.		Relation:	3i.	Citizenship:		3k.		Race:	3m.		Ethnicity:
H	=	head	EC	=	eligible citizen	1	=	White	1	=	Hispanic or Latino
S	=	spouse	EN	=	eligible noncitizen	2	=	Black/African American	2	=	Not Hispanic or Latino
K	=	co-head	IN	=	ineligible noncitizen	3	=	American Indian/Alaska Native
F	=	foster child/foster adult	PV	=	pending verification	4	=	Asian	3q. =		Community Service
Y	=	other youth under 18				5	=	Native Hawaiian/Other Pacific Islander	1	=	yes
E	=	full-time student 18+							2	=	no
L	=	live-in aide							3	=	pending
A	=	other adult							4	=	exception
									5	=	n/a

Previous editions are obsolete

formHUD-50058 MTW (1/2001)

Head of household name

Social Security Number

Date modified (mm/dd/yyyy)

3:MTW Household

Note:	Complete for each household member.
Note:	The first family member (Member number 01) must be the head of household.
Note:	The household includes everyone who lives in the unit. Household members are used to determine unit size. The
	family includes all household members except live-in aides and foster children and foster adults. Family members
	are used to calculate subsidies and payments.
Line 3a:	The Member number identifies the individual listed on that line of the Form.
Line 3b:	Indicate the last name of each household member. Include name suffixes, such as Jr., and separate with a comma.
	Do not include name prefixes, such as Ms. or Mr.
Line 3c:	Indicate the first name of each household member. Do not include name prefixes, such as Ms. or Mr.
Line 3d:	Indicate the middle initial of each household member. If no middle initial, leave blank. If more than one middle initial,
	only enter one.
Line 3e:	Indicate the date of birth for each household member.
Line 3f:	Indicate the age in years of each household member on the effective date of action (line 2b).
Line 3g:	Indicate the gender of each household member (M=Male, F=Female).
Line 3h:	Use code at bottom of page that best categorizes the relation or role of each household member.
Line 3i:	Use code at bottom of page that indicates each household member’s United States citizenship status.
Line 3j:	Indicate whether or not the household member has a disability.
Line 3k:	Use code or codes at bottom of page that the family says best indicates each household member’s race. Select as
	many codes as appropriate.
Line 3m:	Use code at bottom of page and check the box next to the code the family says best indicates each household
	member’s ethnicity.
Line 3n:	Enter the 9-digit Social Security Number (SSN) issued to each household member by the Social Security
	Administration (SSA).
Note:	If family member does not know or have a SSN, enter 999-99-9999.
Line 3p:	Enter the Alien Registration Number or A-number issued to each noncitizen household member, if applicable.
Note:	The A-number contains seven, eight or nine numerical digits preceded by the letter A, e.g., A72 735 827. If the A-
	number has seven digits, enter two zeros before the numbers. If the A-number has eight digits, enter one zero before
	the numbers. If the A-number is nine digits, enter the number without a leading zero. Do not enter the letter A in any
	case.
Line 3q:	Public Housing only. Use code at bottom of page to indicate whether the family member met his or her community
	service requirements under PHRA.
Note:	The law requires an average of eight hours of community service per month during the year.
Note:	Use ‘5’ until the community service requirement comes into effect for your particular PHA.
Line 3r:	Enter the highest grade or the full years of formal schooling that the household member completed (0-25).
Note:	Years of schooling begin with 1st grade (do not count kindergarten or pre-school).
Line 3s:	Indicate whether additional household member information is included on an additional sheet of paper as an
	attachment to the Form.

Previous editions are obsolete

iii

formHUD-50058 MTW (1/2001)

Head of household name

Social Security Number

Date modified (mm/dd/yyyy)

3a. Member

3b.

Last Name & Sr, Jr. etc.

3c. First name

3d. MI

3e. Date of birth

3f. Age on effective

number

date of action

3g.

Sex

3h. Relation

3i.

Citizenship

3j.

Disability (Y/N)

3k. Race

3m. Ethnicity

3n.

Social Security Number

3p. Alien Registration Number

3q. Meeting community service requirement? (Public Housing only)

A-

3r.

Total years of school (0-25)

3a. Member

3b.

Last Name & Sr, Jr. etc.

3c. First name

3d. MI

3e. Date of birth

3f. Age on effective

number

date of action

3g.

Sex

3h. Relation

3i.

Citizenship

3j.

Disability (Y/N)

3k. Race

3m. Ethnicity

3n.

Social Security Number

3p. Alien Registration Number

3q. Meeting community service requirement? (Public Housing only)

A-

3r.

Total years of school (0-25)

3a. Member

3b.

Last Name & Sr, Jr. etc.

3c. First name

3d. MI

3e. Date of birth

3f. Age on effective

number

date of action

3g.

Sex

3h. Relation

3i.

Citizenship

3j.

Disability (Y/N)

3k. Race

3m. Ethnicity

3n.

Social Security Number

3p. Alien Registration Number

3q. Meeting community service requirement? (Public Housing only)

A-

3r.

Total years of school (0-25)

3a. Member

3b.

Last Name & Sr, Jr. etc.

3c. First name

3d. MI

3e. Date of birth

3f. Age on effective

number

date of action

3g.

Sex

3h. Relation

3i.

Citizenship

3j.

Disability (Y/N)

3k. Race

3m. Ethnicity

3n.

Social Security Number

3p. Alien Registration Number

3q. Meeting community service requirement? (Public Housing only)

A-

3r.

Total years of school (0-25)

3a. Member

3b.

Last Name & Sr, Jr. etc.

3c. First name

3d. MI

3e. Date of birth

3f. Age on effective

number

date of action

3g.

Sex

3h. Relation

3i.

Citizenship

3j.

Disability (Y/N)

3k. Race

3m. Ethnicity

3n.

Social Security Number

3p. Alien Registration Number

3q. Meeting community service requirement? (Public Housing only)

A-

3r.

Total years of school (0-25)

Codes:

3h. Relation: H = head

S = spouse

K = co-head

F= foster child/foster adult Y = other youth under 18 E = full-time student 18+ L = live-in aide

A = other adult

3i.	Citizenship:
EC	=	eligible citizen
EN	=	eligible noncitizen
IN	=	ineligible noncitizen
PV	=	pending verification

3k. Race:

1 = White

2= Black/African American

3= American Indian/Alaska Native

4= Asian

5= Native Hawaiian/Other Pacific Islander

3m. Ethnicity:

1= Hispanic or Latino

2= Not Hispanic or Latino

3q. = Community Service

1= yes

2= no

3= pending

4= exception

5= n/a

3s. Continued on an additional sheet?

(Y or N)

3s.

Previous editions are obsolete

formHUD-50058 MTW (1/2001)

Head of household name

Social Security Number

Date modified (mm/dd/yyyy)

3:MTW Household

Note:	Complete for each household member.
Note:	The first family member (Member number 01) must be the head of household.
Note:	The household includes everyone who lives in the unit. Household members are used to determine unit size. The
	family includes all household members except live-in aides and foster children and foster adults. Family members
	are used to calculate subsidies and payments.
Line 3a:	The Member number identifies the individual listed on that line of the Form.
Line 3b:	Indicate the last name of each household member. Include name suffixes, such as Jr., and separate with a comma.
	Do not include name prefixes, such as Ms. or Mr.
Line 3c:	Indicate the first name of each household member. Do not include name prefixes, such as Ms. or Mr.
Line 3d:	Indicate the middle initial of each household member. If no middle initial, leave blank. If more than one middle initial,
	only enter one.
Line 3e:	Indicate the date of birth for each household member.
Line 3f:	Indicate the age in years of each household member on the effective date of action (line 2b).
Line 3g:	Indicate the gender of each household member (M=Male, F=Female).
Line 3h:	Use code at bottom of page that best categorizes the relation or role of each household member.
Line 3i:	Use code at bottom of page that indicates each household member’s United States citizenship status.
Line 3j:	Indicate whether or not the household member has a disability.
Line 3k:	Use code or codes at bottom of page that the family says best indicates each household member’s race. Select as
	many codes as appropriate.
Line 3m:	Use code at bottom of page and check the box next to the code the family says best indicates each household
	member’s ethnicity.
Line 3n:	Enter the 9-digit Social Security Number (SSN) issued to each household member by the Social Security
	Administration (SSA).
Note:	If family member does not know or have a SSN, enter 999-99-9999.
Line 3p:	Enter the Alien Registration Number or A-number issued to each noncitizen household member, if applicable.
Note:	The A-number contains seven, eight or nine numerical digits preceded by the letter A, e.g., A72 735 827. If the A-
	number has seven digits, enter two zeros before the numbers. If the A-number has eight digits, enter one zero before
	the numbers. If the A-number is nine digits, enter the number without a leading zero. Do not enter the letter A in any
	case.
Line 3q:	Public Housing only. Use code at bottom of page to indicate whether the family member met his or her community
	service requirements under PHRA.
Note:	The law requires an average of eight hours of community service per month during the year.
Note:	Use ‘5’ until the community service requirement comes into effect for your particular PHA.
Line 3r:	Enter the highest grade or the full years of formal schooling that the household member completed (0-25).
Note:	Years of schooling begin with 1st grade (do not count kindergarten or pre-school).
Line 3s:	Indicate whether additional household member information is included on an additional sheet of paper as an
	attachment to the Form.

Previous editions are obsolete

formHUD-50058 MTW (1/2001)

Head of household name	Social Security Number	Date modified (mm/dd/yyyy)

3t. Total number in household

3u. Family subsidy status under noncitizen rule: C = Qualified for continuation of full assistance

E= Eligible for full assistance

F= Eligible for full assistance pending verification of status

P= Prorated assistance

3v. Eligibility effective date (mm/dd/yyyy) if qualified for continuation of full assistance (3u = C)

3w. If new head of household, former head of household’s SSN

3t.

3u.

3v.

3w.

4.	MTW Family Background at Admission

4a.	Date (mm/dd/yyyy) entered waiting list		4a.

4b.	ZIP code before admission		4b.

4c.	Homeless at admission? (Y or N)		4c.

4d.	Reserved

4e.	Continuously assisted under the 1937 Housing Act?	(Y or N)	4e.

4f.	Reserved

MTW Unit To Be Occupied on Effective Date of Action

5a.

Unit address

Number and street

Apt.

City

State

Zip code (+4)

5b.

Is mailing address same as unit address?

(Y or N) (If yes, skip to 5d)

5b.

5c.

Family’s mailing address

Number and street

Apt.

City

State

Zip code (+4)

5d.

Number of bedrooms in unit

5d.

5e.

Has the PHA identified this unit as an accessible unit? (Public Housing only)

(Y or N)

5e.

5f.

Has the family requested accessibility features? (Public Housing only)

5f.

(Y or N) (If no, skip to next section)

5g.

Has the family received requested accessibility features? (Public Housing only)

a. Yes, fully

b. Yes, partially

c. No, not at all

d. Action pending (can be checked in

combination with b. or c.)

5h.

Date (mm/dd/yyyy) unit last passed HQS inspection (Tenant-Based or Project-Based Assistance only,

5h.

except Homeownership)

5i.

Date (mm/dd/yyyy) of last annual HQS inspection (Tenant-Based or Project-Based Assistance only, except

5i.

Homeownership)

5j.

Year (yyyy) unit was built (Tenant-Based or Project-Based Assistance only)

5j.

5k. Structure type (check only one) (Tenant-Based or Project-Based Assistance only)

Single family detached

Semi-detached

Rowhouse/townhouse

Low-rise

High rise with elevator

Manufactured home

Note: The numbering for the following sections skips to Section 18. Form HUD-50058 MTW does not contain any sections labeled Section 6 through Section

17.Sections with these numbers were excluded to ensure that data elements on the regular Form HUD-50058 and Form HUD-50058 MTW have unique numerical labels.

Previous editions are obsolete

formHUD-50058 MTW (1/2001)

Head of household name

Social Security Number

Date modified (mm/dd/yyyy)

3:MTW Household (continued)

Line 3t:	The total number of people in the household.
Note:	Count all persons, include foster children or adults, live-in aides, and other unrelated individuals (who reside with the
	family as part of the household). Also include persons who are members of the household but temporarily absent
	from the home.
Line 3u:	Code that indicates the housing assistance eligibility for family members based on the Noncitizens Rule. The
	Noncitizens Rule allows PHAs to provide financial assistance to U.S. citizens, nationals, and non-U.S. citizens with
	eligible immigration status.
Note:	If the family’s status under the Noncitizens Rule is prorated assistance (3u=P), the family should fill out the
	applicable prorated rent calculation when determining rent burden.
Line 3v:	Date the family originally qualified for the continuation of full assistance (3u=C).
Line 3w:	If the designated head of household changed due to discontinued occupancy or other cause such as death,
	marriage, or remarriage and there are family members who remain in the household, enter the former head of
	household’s Social Security Number (SSN).

4:MTW Background at Admission

Line 4a:	Date the PHA placed the family on the waiting list for the program under which they currently receive housing
	assistance.
Note:	This date must not be later than effective date of action (line 2b).
Line 4b:	The 5-digit ZIP code (+4, if applicable) where the family lived before admission to an assistance program.
Line 4c:	Indicate whether or not the family was homeless at the time the PHA admitted the family to a housing assistance
	program.
Line 4d:	Reserved.
Line 4e:	Indicate whether or not the family is continuously assisted under or currently enrolled in any 1937 Housing Act
	program at the time of admission.
Line 4f:	Reserved.
5:	MTW Unit to be Occupied on Effective Date of Action
Line 5a:	The complete address of the housing unit that the household occupies on the effective date of action (line 2b).
Line 5b:	Indicate whether the mailing address is different from the unit address.
Line 5c:	The complete address where the family receives mail, if other than the unit address indicated in line 5a.
Note:	Leave this field blank if the mailing address is the same as the unit address.
Line 5d:	Total number of bedrooms in the unit that the household will occupy on the effective date of action (line 2b).
Line 5e:	Public Housing only. Indicate whether or not the unit that the family occupies on the effective date of action (line 2b)
	is a PHA designated handicapped accessible unit.
Line 5f:	Public Housing only. Indicate whether or not the family requested disability amenities or accessibility features.
Line 5g:	Public Housing only. Indicate the status of the family’s request for disability amenities and/or accessibility features
	(line 5f) on the effective date of action (line 2b).
Line 5h:	Tenant-Based or Project-Based Assistance only, except Homeownership. The last date the unit passed a full
	housing quality standards (HQS) inspection.
Line 5i:	Tenant-Based or Project-Based Assistance only, except Homeownership. The last date a PHA inspector performed a
	full annual housing quality standards (HQS) inspection of the unit that the household occupies.
Note:	This date may be different from the date unit last passed HQS inspection (line 5h) if the unit failed the last HQS
	inspection.
Line 5j:	Tenant-Based or Project-Based Assistance only. Indicate the year that the unit was built.
Note:	This date is found on the request for tenancy approval form.
Line 5k:	Section 8 only. Indicate the building structure type.
Note:	See the Instruction Booklet for descriptions of each housing type.
Note:	The numbering for the following sections skips to Section 18. Form HUD-50058 MTW does not contain any sections
	labeled Section 6 through Section 17. Sections with these numbers were excluded to ensure that data elements on
	the regular Form HUD-50058 and Form HUD-50058 MTW have unique numerical labels.

Previous editions are obsolete

formHUD-50058 MTW (1/2001)

Head of household name

Social Security Number

Date modified (mm/dd/yyyy)

18.MTW Asset Income

18a. Family member				No.		18b.Type of asset				18c.Calculation				18d. Cash value of			18e. Anticipated
name						(PHA use)				(PHA use)				asset				Income
														$			$
														$			$
														$			$
														$			$
														$			$
														$			$
														$			$
														$			$
18f, 18g Column totals														$	18f.		$			18g.
18h. Passbook rate (written as decimal)																	0.			18h.
18i.	Imputed asset income: 18f X 18h (if 18f is $5000 or less, put 0)																$			18i.
18j.	Final asset income: larger of 18g or 18i																				$	18j.
19.MTW Income

19a. Family member			No.		19b. Income				19c. Calculation		19d. Dollars per year				19e. Income			19f. Income after
name						code			(PHA use)						exclusions			exclusions
																		(19d minus 19e)

											$				$			$
											$				$			$
											$				$			$
											$				$			$
											$				$			$
											$				$			$
											$				$			$
											$				$			$
											$				$			$
											$				$			$
											$				$			$
											$				$			$
											$				$			$
											$				$			$
19g, 19h. Column totals											$			19g.				$		19h.
19i. Total annual income: 18j + 19h																					$	19i.

19j.	Deductions															$				19j.

19k.	Adjusted annual income: 19i minus 19j																				$	19k.

19b.	Income Code
Wages:						Welfare:						SS/SSI/Pensions:						Other Income Sources:
B	=	own business				G	=	general assistance				P	=	pension				C	=	child support
F	=	federal wage				IW = annual imputed welfare income						S	=	SSI				E	=	medical reimbursement
HA =		PHA wage				T	=	TANF assistance				SS =		Social Security				I	=	Indian trust/per capita
M	=	military pay																N	=	other nonwage sources
W	=	other wage																U	=	unemployment benefits
																		X	= MTW income

Previous editions are obsolete

formHUD-50058 MTW (1/2001)

Head of household name

Social Security Number

Date modified (mm/dd/yyyy)

18:MTW Assets

Note:	Use a separate line for each family member and asset type.
Line 18a:	The name of each family member in the household that has assets and their Member number (line(s) 3a) that
	corresponds to the asset information reported.
Line 18b:	List any asset that has a dollar value or provides a source of income to the person listed in column 18a.
Note:	See the Form HUD 50058 MTW Instruction Booklet for an explanation of allowable assets.
Line 18c:	Use this column to perform asset calculations.
Line 18d:	Estimated, known or calculated dollar value of the asset listed.
Line 18e:	Total amount of income the family member expects to receive in the next 12-month period from the asset listed.
Line 18f:	Total of the values listed in column 18d.
Line 18g:	Total of the values listed in column 18e.
Line 18h:	Enter the passbook rate as a decimal.
Note:	The HUD field office determines the Passbook rate of interest for the project locality based on the average interest
	rate received on a Passbook Savings Account at several banks in the local area.
Line 18i:	Imputed income from assets based on the total dollar value of the asset listed and the Passbook rate of interest.
Note:	If the total cash value of assets is $5,000 or less, enter 0.
Line 18j:	Total amount of household income derived from assets.

19:MTW Income

Note:	If the family members do not have any income from sources other than assets and do not expect any other income
	in the next 12-month period, leave 19a through 19h blank. Fill in total annual income (line 19i), which would be the
	total of the asset income.
Line 19a:	The name of each family member in the household that has income and their Member number (line(s) 3a) that
	corresponds to the income information reported.
Line 19b:	Use one or two letter code at bottom of page that represents the type of income for a family member.
Note:	See the Form HUD-50058 MTW Instruction Booklet for a detailed description of each income code.
Line 19c:	Use this column to perform income calculations.
Line 19d:	Annual income amount the family member earns from the income source(s) listed.
Note:	See the Form HUD-50058 MTW Instruction Booklet for a description of each income source.
Line 19e:	Income excluded from annual income calculations.
Note:	Includes income disallowance and individual savings accounts (ISA) for Public Housing.
Note:	See the Form HUD-50058 MTW Instruction Booklet for a description of each income exclusion.
Line 19f:	Income minus exclusions. Take dollars per year (line 19d) minus income exclusions (line 19e).
Line 19g:	The total dollar amounts listed in column 19d.
Line 19h:	The total dollar amounts listed in column 19f.
Line 19i:	The family’s total annual income. Add the final asset income (line 18j) and the total income after income exclusions
	(line 19h).
Line 19j.	Total amount of money that is deducted from a family’s income for rent determination purposes.
Line 19k:	The family’s adjusted annual income. Take total annual income (line 19i) minus deductions (line 19j).

Previous editions are obsolete

formHUD-50058 MTW (1/2001)

Head of household name

Social Security Number

Date modified (mm/dd/yyyy)

20. MTW Public Housing

20a.	Type of rent	Income-based	Flat

20b.	Tenant rent			$	20b.

20c.	Mixed family tenant rent			$	20c.

20d.	Utility allowance/estimate			$	20d.

20e.	Is this a ceiling rent? (Y or N)				20f.

20f.	Reserved

21. MTW Tenant-Based or Project-Based Assistance

21a.	Indicate if flat subsidy or income-based subsidy	Income-based	Flat		21a.

21b.	Number of bedrooms on voucher equivalent				21b.

21c.	Is family now moving to this unit? (Y or N)				21c.

21d.	Did family move into your PHA jurisdiction under portability? (Y or N) (if no, skip to 21g)				21d.

21e.	Cost billed per month (put 0 if absorbed)				21e.

21f.	PHA code billed				21f.

21g.	Owner name				21g.

21h.	Owner TIN/SSN				21h.

21i.	Rent to owner			$	21i.

21j.	Utility allowance/estimate			$	21j.

21k.	Gross rent of unit: 21i + 21j (or Space Rent)			$	21k.

21m.Flat subsidy amount, if any				$	21m.

21n.	Tenant rent to owner			$	21n.

21p.	Mixed family tenant rent to owner			$	21p.

21q.	Is this a ceiling rent? (Y or N)				21q.

21r.	Reserved

Previous editions are obsolete

formHUD-50058 MTW (1/2001)

Head of household name

Social Security Number

Date modified (mm/dd/yyyy)

20:MTW Public Housing

Note:	Complete if the family’s program type is MTW Public Housing (line 1c=P) and the type of action is New Admission
	(2a=1), Annual Reexamination (2a=2), Interim Reexamination (2a=3), or Other Change of Unit (2a=7).
Line 20a:	Indicate whether the family pays an income based rent or a flat rent.
Note:	Flat rent is not set by the family’s income.
Line 20b:	The rent amount the family pays to the owner.
Line 20c:	The rent amount the mixed family pays to the owner.
Line 20d:	If the payment does not include all utilities, indicate the monthly allowance amount for tenant supplied utilities that
	applies to the family occupied unit or an estimate of the utility costs.
Note:	If the tenant rent includes all utilities, enter 0.
Line 20e:	Indicate if the family is paying the ceiling rent for this unit.
Line 20f:	Reserved.

21:MTW Tenant-Based or Project-Based Assistance

Note:	Complete if the family’s program type is (1c=PR) for Project-Based Assistance or (1c=T ) for Tenant-Based
	Assistance and type of action is New Admission (2a=1), Annual Reexamination (2a=2), Interim Reexamination
	(2a=3), Portability Move-in (2a=4), or Other Change of Unit (2a=7).
Line 21a:	Indicate whether the family pays an income based subsidy or a flat subsidy.
Note:	Flat subsidies are not set by the family’s income.
Line 21b:	Unit size (number of bedrooms) listed on the family’s voucher equivalent.
Line 21c:	Indicate if the family is now moving into the unit.
Line 21d:	Indicate whether or not the household will move or has moved into the PHA’s jurisdiction under portability.
Line 21e:	Monthly amount billed to the initial PHA for the family’s housing assistance payment (HAP), on-going administrative
	fee, and any utility reimbursement to the family.
Note:	Enter 0 if the family was absorbed by the receiving PHA.
Line 21f:	The initial PHA’s 2-letter state code and 3-digit identification number.
Note:	For help obtaining the initial PHA’s identification number, contact the appropriate HUD field office, the HA Profiles
	Web Site within PIC or the MTCS Hotline at 1-800-FON-MTCS.
Line 21g:	The unit owner’s legal name.
Line 21h:	Tax identification number (TIN) or Social Security Number (SSN) of the legal unit owner.
Line 21i:	Total monthly rent payable to the unit owner under the lease for the contract unit.
Line 21j:	If the payment does not include all utilities, indicate the monthly allowance amount for tenant supplied utilities that
	apply to the family occupied unit or an estimate of utility costs.
Note:	If the payment includes all utilities, enter 0.
Line 21k:	Gross rent of unit or space rent. Add rent to owner (line 21i) to the utility allowance (line 21j).
Line 21m:	Amount of monthly flat subsidy that the PHA provides to unit owner, if any (line 21a=F).
Line 21n:	Rent amount the family pays to the owner.
Line 21p:	Rent amount the mixed family pays to the owner.
Line 21q.	Indicate if the family is paying the ceiling rent for this unit.
Line 21r:	Reserved.

Previous editions are obsolete

vii

formHUD-50058 MTW (1/2001)

Head of household name

Social Security Number

Date modified (mm/dd/yyyy)

22.	MTW Homeownership

22a.	Indicate if flat subsidy or income-based subsidy				22a.
		Income-based	Flat

22b.	Is family now moving to this home? (Y or N)				22b.

22c.	Date (mm/dd/yyyy) of initial HQS inspection				22c.

22d.	Did family move into your PHA jurisdiction under portability? (Y or N)				22d.
	(if no, skip to 22g)

22e.	Cost billed per month (put 0 if absorbed)				22e.

22f.	PHA code billed				22f.

22g.	Monthly homeownership payment (PITI & MIP if applicable)			$	22g.

22h.	Utility allowance/estimate			$	22h.

22i.	Other monthly allowance(s), if any			$	22i.

22j.	Gross homeownership expense			$	22j.

22k.	Flat subsidy amount			$	22k.

22m.	Total family share					$	22m.

22n.	Mixed family total family share					$	22n.

22p.	Is this a ceiling family share? (Y or N)				22p.

22q.	Reserved

Previous editions are obsolete

formHUD-50058 MTW (1/2001)

Head of household name

Social Security Number

Date modified (mm/dd/yyyy)

22:MTW Homeownership

Note:	Complete if program type is Homeownership (line 1c=PR) or (line 1c=T) and type of action is New Admission (2a=1),
	Annual Reexamination (2a=2), Interim Reexamination (2a=3), Portability Move-in (2a=4), or Other Change of Unit (2a=7).
Line 22a:	Indicate if flat subsidy or income-based subsidy.
Note:	Flat subsidies are not set by the family’s income.
Line 22b:	Indicate if the family is now moving into the home.
Line 22c:	Date of the initial housing quality standards (HQS) inspection.
Line 22d:	Indicate whether or not the household will move or has moved into the PHA’s jurisdiction under portability.
Line 22e:	Monthly amount billed to the initial PHA for the family’s housing assistance payment (HAP) amount, on-going
	administrative fee, and any utility reimbursement to the family.
Note:	Enter 0 if the family was absorbed by the receiving PHA.
Line 22f:	The initial PHA’s 2-letter state code and 3-digit identification number.
Note:	For help obtaining the initial PHA’s identification number, contact the appropriate HUD field office, the HA Profiles Web
	Site within PIC or the MTCS Hotline at 1-800-FON-MTCS.
Line 22g:	The monthly homeownership cost.
Note:	Includes principal and interest on initial mortgage debt, taxes and insurance (PITI) and any mortgage insurance premium
	(MIP), if applicable.
Line 22h:	The PHA’s utility allowance for the unit.
Note:	If the PHA does not provide a utility allowance, enter an estimate of utility costs.
Line 22i:	The amount of PHA’s allowances for the homeowner’s monthly routine maintenance costs, major home repairs and
	maintenance, and co-op/condominium assessments.
Line 22j:	Calculation of tenant’s total cost of homeownership. Sum of 22g through 22i.
Line 22k:	Total monthly amount of subsidy the PHA contributes toward homeowners if a flat subsidy is provided to the family.
Line 22m.	Total amount the family contributes toward homeownership.
Line 22n:	Indicate the mixed family total family contribution based on the proration calculation.
Line 22p:	Indicate if the family is paying the ceiling payment for this unit.
Line 22q:	Reserved.

Previous editions are obsolete

viii

formHUD-50058 MTW (1/2001)

Head of household name

Social Security Number

Date modified (mm/dd/yyyy)

23. Family Self Sufficiency (FSS)/MTW Self Sufficiency Addendum

23a. Participate in special program? (check no more than one)

FSS

MTW self-sufficiency

23b.	Report category (check no more than one)	Enrollment	Progress	Exit
23c.	Effective date (mm/dd/yyyy) of self-sufficiency action
23d.	PHA code of PHA administering contract
23e.	Reserved
23f.	Reserved
23g.	Reserved
23h.	General Information

(1)Current employment status of head of household. Check the box to indicate the head of househo ld’s employment status at the time Addendum completed.

Full-time (32 hours per week or more)

Part-time

Not employed

23c.

23d.

(2)

Date (mm/dd/yyyy) current employment began

23h(2).

(3)

Benefits in current employment: (check all that apply)

Hea lth

Retirement account

Other

(4)

Reserved

23h(4).

(5)

Assistance received by the family: (check all that apply)

TANF Income Assistance?

General Assistance?

Food Stamps?

Medicaid/Children’s Health Insurance Program?

Earned Income Tax Credit?

(6)

Number of children receiving child care services

23h(6).

23i. Family services table

(1) Need

(2) Needs Met Through

(3) Service Provider

(Y or N)

Program

(Y or N)

Education/Training

GED

High school

Post secondary

Vocational/job training

Job search/job placement

Job retention

Transportation

Health services

Alcohol and other drug abuse prevention services

Mentoring

Homeownership counseling

Individual Development Account (IDA)

Child care

None

23i (3) Service Provider Codes
P	=	PHA	D	=	DOL grantee	PR =	For profit entity	E	=	Employer
T	=	TANF agency	V	=	Voluntary organization	N =	Nonprofit agency	C	=	Community college

Previous editions are obsolete

formHUD-50058 MTW (1/2001)

Head of household name

Social Security Number

Date modified (mm/dd/yyyy)

23:Family Self-Sufficiency (FSS)/MTW Self Sufficiency Addendum

Note:	Complete this section if the family participates in the Family Self-Sufficiency or an MTW self-sufficiency program.
Line 23a:	Identify if the family participates in a Family Self-Sufficiency (FSS) program or an MTW self-sufficiency program.
Line 23b:	Check one category to indicate the purpose of the FSS Addendum.
Line 23c:	The effective date of the self-sufficiency action.
Line 23d:	The PHA code associated with the PHA that provides the self-sufficiency services.
Note:	For help obtaining the PHA’s identification number, contact the appropriate HUD field office, the HA Profiles Web Site
	within PIC or the MTCS Hotline at 1-800-FON-MTCS.
Line 23e:	Reserved.
Line 23f:	Reserved.
Line 23g:	Reserved.
Line 23h.(1):	Indicate the head of household 's current employment status.
Line 23h.(2):	The date the head of household began his/her current job.
Line 23h.(3):	Indicate the head of household’s current employment benefits. Check all that apply.
Line 23h.(4):	Reserved.
Line 23h.(5):	Indicate whether or not the family receives additional assistance, such as food stamps, Medicaid, TANF assistance,
	or the earned income tax credit.
Line 23h.(6):	Indicate the number of children in the household who receive childcare services.
Line 23i.(1):	Indicate whether or not the PHA identified individual training and service needs of the family members.
Line 23i.(2):	If the PHA identified certain needs for family members, indicate whether or not the program meets these needs.
Line 23i.(3):	Using the codes provided at bottom of page, indicate the type of service provider that meets the participant’s need.

Previous editions are obsolete

formHUD-50058 MTW (1/2001)

Head of household name

Social Security Number

Date modified (mm/dd/yyyy)

23j.	Self-Sufficiency Contract Information

	(1)	Initial start date (mm/yyyy) of contract of participation		23j(1).

	(2)	Initial end date (mm/yyyy) of contract of participation		23j(2).

	(3)	Contract date (mm/yyyy) extended to (if applicable)		23j(3).

	(4)	Number of family members with Individual Training and Services Plan		23j(4).

	(5)	Did the family receive selection preference because of a related service program participation?		23j(5).
		(Y or N)

23k.	Escrow Account Information

	(1)	Current account monthly credit	$	23k(1).

	(2)	Current account balance	$	23k(2).

	(3)	Account amount disbursed to the family (cumulative as of end of reporting period)	$	23k(3).

23m.	Exit Information (complete only for Exit Report)

(1)Did family complete FSS contract of participation or MTW self-sufficiency program? (Y or N)

(2)If (1) is Yes, did family move to homeownership? (Y or N)

(3) If (1) is No, reason for exit:		Left voluntarily	Asked to leave program	Portability move-out
	Left because essential service was unavailable		Contract expired but family did not fulfill obligations
	Left because essential service was unavailable		Contract expired but family did not fulfill obligations

Previous editions are obsolete

formHUD-50058 MTW (1/2001)

Head of household name

Social Security Number

Date modified (mm/dd/yyyy)

23:Family Self-Sufficiency (FSS)/MTW Self Sufficiency Addendum (continued)

Line 23j.(1): Enrollment report only. The effective date of the family’s contract of participation; the date the family initially enrolled in the self-sufficiency program.

Line 23j.(2): Enrollment report only. The expiration date of the family’s contract of participation; the date the family is initially expected to exit the self-sufficiency program.

Line 23j.(3): If applicable, the date to which the PHA has extended the family’s contract of participation.

Line 23j.(4): The number of family members in the household who have current Individual Training and Services Plans under the contract of participation.

Line 23j.(5): For new enrollment, indicate whether or not the family received a selection preference due to participation in a related service program.

Line 23k.(1): The current dollar amount credited to the family’s account due to increases in earned income by the family.

Line 23k.(2): The current dollar amount of the family’s account based on the most recent report of account funds and activity.

Line 23k.(3): Total dollar cumulative amount, if any, of all escrow disbursements ever made to the family.

Line 23m.(1): Indicate if the family fulfilled all of its obligations under the contract during the contract term.

Line 23m.(2): Indicate if the family completed the contract and is moving to homeownership.

Line 23m.(3): Indicate why the family did not complete its FSS or MTW self-sufficiency contract

Previous editions are obsolete

formHUD-50058 MTW (1/2001)

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