Form HUD-52663-52665 Suggested Format for Requisition for Partial

Suggested Format for
Requisition for Partial
Payment of Annual Contributions

OMB Approval No. 2577-0169
(Exp. 05/31/2004)

U.S. Department of Housing
and Urban Development
Office of Public and Indian Housing

Section 8 Housing Assistance Payments Program
Public reporting burden for this collection of information is estimated to average 1.5 hours per response, including the time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This agency may not conduct or sponsor, and
you are not required to respond to, a collection of information unless that collecton displays a valid OMB control number. Authority for this collection of information
is the Housing and Community Development Act of 1987. Housing Agencies (HAs) required to maintain financial reports in accordance with accepted accounting
standards too permit timely and effective audits. The financial records identify the amount of annual contributions that are received and disbursed by HAs. Responses
to the collection of information are required to obtain a benefit or to retain a benefit. The information requested does not lend itself to confidentiality.
1. Date of Requisition (mm/dd/yyyy)

2. No. of Months in 1st FY

4. Public Housing Agency (HA) (Name and Address)

3. Project Number

5. Housing Program Type (Mark one)

(a) Moderate Rehabilitation
(b) Rental Certificates

(c) Rental Vouchers

6. HA Fiscal Year Ending Date (Mark one box and complete year)

March 31,

June 30,

7. Number of Units Under Lease 8. Average Monthly Housing
9. Estimated Number of Units
to Eligible Families as of
Assistance Payment Per Unit
to be Under Lease at End
Date of Requisition
as of Date of Requisition
of Requested Year

September 30,

10. Unit Months Under Lease
Year to Date

December 31, (YYYY) ________
11. Average Monthly Housing
Assistance Payment Per Unit
Year to Date

Funds Required
for Requested Year
12. Preliminary Administrative and General Expense
13. Estimated Housing Assistance Payments (Account 4715)
14. Estimated Ongoing Administrative Fee
15. Estimated Hard-to-House Fee (Existing Housing Certificates and Housing Vouchers Only)
16. Independent Public Accountant Audit Costs (Section 8 Only)
17. Total Funds Required to End of Requested Year (Sum of Lines 12 through 16)
18. Payments Previously Approved for the Fiscal Year (applicable only to revised requisition)
19. Adjustment to Requisition (Difference of Line 17 and Line 18. Do not use brackets)
20. Total Payment Requirement For Requested Year (Line 18 plus or minus adjustment on Line 19 if revised requisition. Total must equal Line 17)
21.

Paid in Equal Installments (Original Requisition Only)

22. Installment

Paid in Unequal Installments

1

2

3

4

5

6

7

8

9

10

11

12

HA Total
HUD Revision
Installment
HA Total
HUD Revision
23a. Total (HA)
$

23b. Total (HUD)
$

24. Revised Monthly Installments
Begin Month Of:

I Certify that (1) housing assistance payments have been or will be made only in accordance with Housing Assistance Payments Contracts or Housing Voucher contracts
in the form prescribed by HUD and in accordance with HUD regulations and requirements; (2) units have been inspected by the HA in accordance with HUD regulations
and requirements; and (3) this requisition for annual contributions has been examined by me and to the best of my knowledge and belief is true, correct and complete.
Warning: HUD will prosecute false claims and statements. Conviction may result in criminal and/or civil penalties. (18 U.S.C. 1001, 1010, 1012; 31 U.S.C. 3729, 3802)
Title of Authorized HA Official

Signature

Previous editions are obsolete

Title of Authorized HUD Approving Official

Date (mm/dd/yyyy)

Signature

Date (mm/dd/yyyy)

form HUD-52663 (9/94)
ref Handbook 7420.7