HUD-VASH supplemental (HUD-50058) — post-referral packet

Family Report supplemental form for the local Housing Authority once your VA case manager has referred you to HUD-VASH

Audience · Veterans who already have a VA case manager and have been (or are about to be) referred to HUD-VASH. If you don't yet have a VA case manager, start with the va-1010ez wizard first.Time · ~20 min

1Fill it out
2Review
3Sign
4Download

VA referral status

HUD-VASH cannot start without a VA referral. If you don't yet have a VA case manager, complete the va-1010ez wizard first and request HUD-VASH from your case manager.

Has your VA case manager already referred you to HUD-VASH?

VA case manager's full name

VA case manager's phone or email

Date the case manager filed the referral (or expected date)

Are you connected to a nearby military installation / regional VA system?

Installation-connected vets: your case manager will route the referral through the managing regional VA campus — your unit search still happens in the Antelope Valley.

Veteran identity

Full legal name

Date of birth

Social Security number (required by HUD)

HUD requires SSN for income verification (24 CFR §5.216). Default: leave blank here and bring your SSN card to the Housing Authority briefing. Tap 'Enter digitally' below to encrypt your SSN for a fully-completed PDF (decrypted only in-memory; auto-deletes 30 days after submission).

Phone

Current address (or describe location if unhoused)

If you're escaping abuse or unsafe at your current address, ask the partner where you'll submit this form whether you can use a safe-address (FJC, library, or partner agency). We won't track which address you used.

How we handle addresses →

Household members on the voucher

HUD-VASH vouchers cover the veteran plus eligible household members. List everyone who will live in the assisted unit.

Total household size (including the veteran)

List each household member (name, age, relationship, SSN status)

Example: 'Maria, 38, spouse, has SSN; Luis, 7, son, has SSN.' SSNs for household members are required by HUD for citizens/eligible immigrants age 6+.

School enrollment status of any children under 18

Income — all sources

HUD calculates your rent share at 30% of adjusted income. Be complete — under-reporting voids the voucher.

VA benefits income (disability comp, pension) — monthly

SSI / SSDI income — monthly

Earned income (wages, self-employment) — monthly

Other income (pensions, unemployment, child support received, etc.)

Total household annual income (sum × 12)

Special needs + accessibility

Disability disclosure is optional. If you disclose, you may be prioritized for accessible units.

Mobility accessibility needs (ramp, no stairs, roll-in shower)?

Hearing or vision accommodation needs?

Service or emotional-support animal?

Antelope Valley cities you'd accept

Cities in the Antelope Valley you would accept a unit in

Example: 'Lancaster, Palmdale.' Listing more cities = faster placement.

Race / ethnicity (optional — HUD demographic reporting only)

Optional. HUD collects this for federal civil rights reporting; refusal does not affect your voucher.

Anything the HA + VA case manager should know

Your housing situation in your own words

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