Redline HUD-5980A

Tribal HUD VASH Family Report

INSTRUCTIONS and DEFINITIONS
ELIGIBLE VETERAN
Name
Social Security #
Date Modified

Enter the Eligible Veteran's Last Name, First Name, Middle Initial.
Enter the Eligible Veteran's Social Security Number.
Enter the date the Tribal/TDHE representative fills out the form or modifies any form
page.

TRIBAL HUD VASH GRANTEE INFORMATION
Input start date beginning 10/1/YYYY and End Date 9/30/YYYY. For example, for the
Current Federal Fiscal
FY2023 Federal Fiscal Year the start date would be 10/1/2022 and End date
Year
9/30/2023.
Name of the Tribe/TDHE that completes the family's Form
Tribe/TDHE
Five-character code composed of the 2-letter postal state code and 3-digit number.
For help obtaining the Tribe/TDHEs identification number, contact the Tribe/TDHE
TDHE Code
assigned Grants Management Specialist in the area ONAP.
Select from the drop down
This type of rental housing assistance is tied to a specific housing unit or units in a
project developed for a specific population. The housing assistance stays with the
Tribal HUD VASH unit or units and any household living in the unit must meet program requirements. If
Project Based the household moves out of the subsidized unit, the household no longer receives
rental housing assistance

Program

This type of rental housing assistance is not tied to a specific unit or development,
but can be used in any qualifying open-market unit. The eligible applicant selects and
rents a unit (whether private or TDHE-owned) that meets program requirements, and
Tribal HUD VASH the tribe or TDHE makes rent subsidy payments on behalf of the household. The
Tenant Based assistance stays with the household; if the household moves to a different unit that
meets program qualifications, the tribe or TDHE makes rental payments to the owner
of the new unit on the household’s behalf.

ACTION
Select the appropriate action from the drop down
Type of Action
New Admission Eligible Veteran is a new admission to program or changes programs.
Annual
Reexamination The regularly scheduled annual reexamination of family income and circumstances
The reexamination of family income and circumstances, other than at the regularly
Interim
scheduled annual reexamination. An interim reexamination occurs at the request of
Reexamination
the tenant as a result of a change in income status, addition or loss of a family
member, or other circumstance that requires tenant rent adjustment.
Eligible Veteran and all family members discontinue participation in the Tenant Based
End of Participation or Project Based program. Report an End Participation if the family moves from one
program to another.

Historic Adjustment
Effective Date of
Action
Correction
Reason for Correction
Date Eligible Veteran
Admitted to Program
Date of Next
Reexamination
Effective Date of
Reexamination

To capture information for households who do not have a New Admission recorded
but require an action other than a new admission, annual reexamination or interim
reexamination. Historical Adjustment will serve as the baseline action for the
household.
Date the reported action becomes effective. The effective date cannot be earlier
than the date of admission to the program
Select from the drop down
Indicate the primary reason for the correction record. Requires Tribe/TDHE to
indicate the reason for a correction.
Date the Tribe/TDHE initially admitted the family into the Project Based or Tenant
Based program reported in Tribal VASH Grantee Information section. HUD uses this
date to determine how long families participate in specific housing programs.
Scheduled date for the next reexamination
The projected effective date of reexamination.

HOUSEHOLD

NOTE:

Household Member
Name
Date of Birth
Social Security #
Tribal Member
Veteran
Race
Ethnicity
Sex

Relation

Complete for each household member. The first family member (member number
01) must be the head of household and Eligible Veteran. The household includes
everyone who lives in the unit. Household members are used to determine unit size.
The family includes all household members except live-in aides and foster children
and foster adults. Family members are used to calculate subsidies and payments
Include Last Name, Suffix (jr., II, III), First Name, Middle Initial (Eligible Veteran Name
will auto populate for Household member 01)
Date of Birth of Identified Member
Input Social Security # for Identified Member. Enter CDIB# if household member
does not have a Social Security Number. (Eligible Veteran SSN will auto populate for
member 01)
Select from the drop down
Select from the drop down. (Eligible Veteran Member 01 will auto populate)

Choose from drop down- White, Black/African American, American Indian/Alaskan
Native, Asian, Native Hawaiian/Other Pacific Islander.
Select from drop down- Hispanic or Latino, Not Hispanic or Latino
Indicate the gender sex of each household member. Select "Other" when the
applicant identifies as a gender other than Male or Female (M= Male, F= Female,
Other).
Select the code at bottom of the page that best categorizes the relation or role of
each household member. The veteran should be entered as the Head of household.
All other relationships should identify household members relationship to the
veteran.
Self Eligible Veteran and Head of Household
Spouse The marriage partner of the Eligible Veteran and head of household.

Household member who is equally responsible for the lease with the head of
household. Indicate either a spouse or a co-head, but not both. A co-head never
Co-head of
qualifies as a dependent. However, a co-head may be under 18 years old if declared
Household
an “emancipated minor”, as many states will allow an emancipated minor to sign a
lease.

Foster child – A member of the household who is under 18 years of age or a member
who is a full-time student, 18 years or older, and who is under the parental control
Foster Child/Adult
and responsibility of someone other than his or her mother or father.
Foster adult – A member of the household (usually a person with a disability,
unrelated to the tenant family, who is unable to live alone) who is 18 years of age or
older and for whom the family provides necessary shelter, care and protection
Other Youth under Member of the household (regardless of disability status), who is under 18 years of
18 age on the effective date of action, and is not a foster child

Full Time Student
18+

Live-in Aide

Other Adult

Member of the household, other than the Head, spouse or cohead, or foster child or
adult, 18 years of age or older on the effective date of action (line 2b) who carries a
subject load considered full-time for students under the standards and practices of
the educational institution attended. An educational institution includes a vocational
school with a diploma or certificate program, as well as a degree-granting institution.
A person who lives with an elderly or disabled person(s) and who: is determined to
be essential to the care and well-being of the person(s); is not obligated to support
the person(s); would not be living in the unit except to provide necessary supportive
services
A member of the household (excludes foster adults), other than the head or spouse
or co-head, who is 18 years of age or older on the effective date of action , regardless
of disability status
Select from the drop down
Will auto calculate based on date of action minus date of birth of identified
household member.

Disability
Age on Effective Date
of Action
Total Number in
Will auto calculate based on the number of household member sections completed
Household

Bedrooms for
Household

Former Head of
Household SSN#

Insert number of required bedrooms based on composition of household. Bedroom
size must be determined based the number of family members living in the
household, not on the number of bedrooms in the unit to be rented. Guidelines for
determining unit size are one bedroom for each two persons within the household,
except a. Persons of the opposite sex (other than spouses, and children under age 5)
are not required to share a bedroom; b. Persons of different generations are not
required to share a bedroom; c. Live-in aides must be allocated a separate bedroom.
No additional bedrooms will be provided for the live-in aide’s family; and d. Single
person families must be allocated zero or one bedroom.
Therefore, in situations where the available housing has more bedrooms than
necessary for the family size and composition, the rental assistance payment must be
limited to the number of bedrooms based on the guidelines listed above. If a
recipient chooses to ‘‘over house’’ a Veteran family by placing the family in a larger
unit than the family requires under the above guidelines, the maximum amount of
Tribal HUD–VASH funds that can be used to house the Veteran family is the rent for a
unit sized in accordance with the guidelines, and in accordance with Section VI.,
subsection H of this Notice. Any additional rental costs due to over housing cannot be
funded with Tribal HUD–VASH or regular IHBG funds, but can be funded by other
resources. In addition, Tribes/TDHEs may want to consider shared housing
arrangements in situations where appropriate-sized housing is limited, but where
individual veterans could have a separate bedroom and share common areas.
If there is a change in Head of Household, input former head of household's SSN

BACKGROUND AT ADMISSION
ZIP Code before
Admission
Homeless/At Risk of
Homelessness

The 5-digit ZIP code where the family lived before admission to an assistance
program.
Indicate whether or not the family was homeless or at risk of homelessness at the
time the Tribe/TDHE admitted the family to a housing assistance program.

UNIT TO BE OCCUPIED ON ACTION EFFECTIVE DATE
Unit Address
Mailing Address
Bedrooms

The complete address of the housing unit that the household occupies on the
effective date of action.
Provide mailing address if different than unit address to be occupied.
Total number of bedrooms in the unit that the household will occupy on the effective
date of action
Select type from the drop down

Structure Type
Single Family
Detached Building structures that house only one family under one roof
Semi-detached Includes units in duplexes and two-family homes.
Rowhouse/Townhou
se Includes structures with three or more units side-by-side and under one roof.

Multifamily apartment buildings of five or more units and up to four stories. Also
Low-rise include five or six story buildings without an elevator as low-rise structures.
High Rise Elevator Buildings of five stories or more with elevators.
Includes mobile homes
Manufactured Home
Lease Start/End
Bedroom Difference
Justification
Type of Property

Date Unit Lease Begins and Ends.
Provide justification for over housing family or allowing unit with more bedrooms
than needed. Note that any additional rental costs due to over housing cannot be
funded with Tribal HUD–VASH or IHBG funds.
Select option from drop down. Tribally/TDHE Owned, Privately Owned or Subsidized
with other Federal Assistance

TOTAL TENANT PAYMENT
Total Monthly Tenant Enter the tenant’s rent contribution. Tenant rent must not exceed 30 percent of the
household’s adjusted monthly income.
Payment

PROJECT BASED ASSISTANCE
Bedrooms
Owner Name
Owner TIN/SSN #
Contract Rent
Utility Allowance

Gross Rent

Total number of bedrooms in the unit that the household will occupy on the effective
date of action
Legal Name of the Property Owner where Unit is Located.
Tax identification number (TIN) or Social Security Number (SSN) of the legal unit
owner.
Total monthly rent amount paid to the unit owner in accordance with the lease
agreement.
If the rental payment does not include all utilities, indicate the monthly allowance
amount for tenant supplied utilities that apply to the family occupied unit.
Identified as Total Rent Amount in Consolidation Notice. Auto Calculates. The unit’s
total monthly rent amount is determined by adding the contract rent to owner to the
utility allowance.

TTP

Identified as Tenant Rent Contribution in Consolidation Notice. TTP auto calculates
based on the amount established in the Total Tenant Payment section.

Contribution Funds

Input the amount the tribe/TDHE paid using funds outside of the Veteran household's
contribution and the Tribal HUD-VASH funding (RAP payment).
Fair Market Rent for the area where unit is located.
110% of Fair Market Rent for the area where unit is located.

FMR
110% of FMR
Monthly Rental
Assistance Payment
(RAP)
Total RAP to Owner
Is Family Moving In
HUD Approval to
Exceed 110% of FMR

Total rental assistance payment (RAP) equals the gross rent of unit minus total tenant
payment (TTP).
Total Rental Assistance Payments made to Owner over the Leasing Period
Is family moving from another unit to this unit

Was HUD approval obtained for Lease that exceeds 110% of the Fair Market Value.

Justification

Provide justification for lease that exceeds 110% of Fair Market Rent.

TENANT BASED ASSISTANCE
Bedrooms
Owner Name
Owner TIN/SSN #

Rent to Owner

Utility Allowance

Gross Rent

The unit size (number of bedrooms) listed on the voucher issued to the family. This
may be different than the number of bedrooms listed in Unit to be Occupied on
Action Effective Date (Number of bedrooms in the unit). Enter 0 (zero) for an
efficiency or Single Room Occupancy (SRO) unit.
Legal Name of the Property Owner where Unit is Located.
Tax identification number (TIN) or Social Security Number (SSN) of the legal unit
owner.
Total monthly rent payable to the unit owner under the lease for the unit. For rental
of a manufactured home space, enter the rent to owner for the space including any
owner maintenance or management charges for the space.
If the rental payment does not include all utilities, indicate the monthly allowance
amount for tenant supplied utilities that apply to the family occupied unit.
Identified as Total Rent Amount in Consolidation Notice. Auto Calculates. The unit’s
total monthly rent amount is determined by adding the contract rent to owner to the
utility allowance.

TTP

Identified as Tenant Rent Contribution in Consolidation Notice. TTP auto calculates
based on the amount established in the Total Tenant Payment section.

Contribution Funds
FMR
110% of FMR
Rental Assistance
Payment (RAP)

Input the amount the tribe/TDHE paid using funds outside of the Veteran household's
contribution and the Tribal HUD-VASH funding (RAP payment).
Fair Market Rent for the area where unit is located.
110% of Fair Market Rent for the area where unit is located.
Total rental assistance payment (RAP) equals the gross rent of unit minus total tenant
payment (TTP).

Total RAP to Owner
Is Family Moving In

Total Rental Assistance Payments made to Owner over the Leasing Period
Is family moving from another unit to this unit

HUD Approval to
Exceed 110% of FMR
Justification

Was HUD approval obtained for Lease that exceeds 110% of the Fair Market Value.
Provide justification for lease that exceeds 110% of Fair Market Rent.

Program Code
Structure Type
Tribal HUD VASH Tenant
Single
Based
Family
Assistance
Detached
Tribal HUD VASH Project
Semi-detached
Based Assistance
Rowhouse/Townhouse
Yes
Low-rise
No
High Rise Elevator
Manufactured Home
Relationship Code
Self
Correction
Spouse
Family Correction (Income)

Child
Parent
Other Adult
Other Child
Live-in Aide
Gender Sex
M
F
Other
Ethnicity

Family Correction (Non-Income)
TDHE Correction (Income)
TDHE Correction (Non-Income)
Type of Actions
New Admission
Annual Reexamination
Interim Reexamination
End Participation
Historical Adjustment
Type of Property
Hispanic or Latino
TDHE/Tribally Owned
Not Hispanic or Latino Privately Owned
Other Federally Subsidized
Race
White
Black/African American
American Indian/Alaskan Native
Asian
Native Hawaiian/Other Pacific Islander