HUD-52665 Family Portability Information

Family Portability Information
Housing Choice Voucher Program

OMB Approval No. 2577-0169
(exp.07/31/2007)

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

Public reporting burden for this collection of information is estimated to average .50 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 a person is not required to respond to, a collection of information unless that collection displays a valid OMB control number.
This collection of information is authorized under Section 8 of the U.S. Housing Act of l937 (42 U.S.C. 1437f). The information is used to standardize the information
submitted to the receiving Public Housing Agency (PHA) by the initial PHA. In addition, the information is used for monthly billing by the receiving PHA.
Sensitive Information. The information collected on this form is considered sensitive and is protected by the Privacy Act. The Privacy Act requires that these records
be maintained with appropriate administrative, technical, and physical safeguards to ensure their security and confidentiality. In addition, these records should be
protected against any anticipated threats or hazards to their security or integrity which could result in substantial harm, embarrassment, inconvenience, or unfairness
to any individual on whom the information is maintained.

Part I Initial PHA Information and Certification
Instructions: This portion of the form is to be completed by the initial PHA for a family that is moving out of the initial PHA’s jurisdiction under the portability procedures.
1. Head of Household Name

3. Voucher Number

2. Head of Household Social Security Number

4.Bedroom Size

5. Issuance Date
(mm/dd/yyyy)

6. Expiration Date
(mm/dd/yyyy)

7. Date of Last Income Examination
(mm/dd/yyyy)

8.

Annual income if new admission (not currently a voucher participant)

$ __________________________

9.

Date by which initial billing must be received (60 days following the expiration date of the initial PHA voucher)(mm/dd/yyyy) _______________________

10. 80% of initial PHA ongoing administrative fee

$ __________________________

11. Receiving PHA to which family has been referred: __________________________________________________.

Attachments:
a. A copy of the voucher issued by the initial PHA.
b. A copy of the current form HUD-50058 and copies of the income verification for the current form HUD-50058. (Note: This
is the latest form HUD-50058 completed for either an admission, an annual reexamination, or an interim redetermination. It is not
the form HUD-50058 that the initial PHA completes to report the portability move-out.)
Certification Statement:
The family
is a current program participant or
is not a current program participant but is income-eligible in the receiving PHA’s
jurisdiction (see line 8 above), and the voucher was issued in accordance with the program regulations. Please issue the family a receiving
PHA voucher that does not expire before the expiration date indicated in Item 6 (the expiration date on the initial PHA’s voucher) for
the appropriate bedroom size (based on the receiving PHA’s policies). I certify that the information contained on Part I of this form and
the attached documents provided by my agency is true and correct. My agency will promptly reimburse amounts paid on behalf of the
above family within 30 calendar days of receipt of Part II of this form and thereafter ensure that subsequent billing payments are received
by your agency no later than the fifth working day of each month. Failure to comply with these payment due dates may result in the
transfer of the family's voucher in accordance with program rules and regulations.

Name of Certifying PHA Official _____________________________________

Signature

______________________________________

Initial PHA Contact Name

______________________________________

Phone Number

______________________________________

Type full Name and Address of Initial PHA below

Form Submission Date (mm/dd/yyyy) _________________

This form may be reproduced on local office copiers

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form HUD-52665 (05/2004)
ref. Handbook 7420.8

Part II-A Receiving PHA Information and Certification
Instructions: The receiving PHA must always complete Part II-A.
1.Head of Household Name

2.Head of Household Social Security Number

3.Voucher Bedroom Size (per receiving PHA’s policies)

4.HAP Contract Number (if applicable)

Certification Statement:
I certify that the information contained on Part II of this form and, if applicable, the attached form HUD-50058 is true and correct and
that my agency will promptly remit any overpayment to your agency.
Name of Certifying PHA Official _____________________________________

Signature

Type full Name and Address of Receiving PHA below

______________________________________

Receiving PHA Contact Name ______________________________________

Phone Number

______________________________________

Form Submission Date (mm/dd/yyyy) _________________

Part II-B Family Status, Initial HAP Contract Execution and Billing Changes After HAP Contract Execution
Instructions: Part II-B must be completed and mailed by the receiving PHA within 10 working days from the date a HAP contract is executed on behalf of
the family, or from the effective date of the change in the family status or billing amount. The receiving PHA does not submit the billing form each month
unless the monthly amount due changes or both PHAs agree to a different billing schedule that requires a more frequent billing submittal.

Check each statement below that applies:
1. The above family has failed to submit a request for lease approval for an eligible unit within the allotted time period. You may therefore
reissue your voucher to another family and, if applicable, modify any records concerning local preference usage and income targeting
requirements. Do not complete remainder of form.
2. We have executed a HAP contract on behalf of the family and are absorbing the family into our own program effective
_____________(mm/dd/yyyy). You may reissue your voucher to another family. Do not complete remainder of form.
3. We executed a HAP contract effective __________________ (mm/dd/yyyy) on behalf of the family and are billing your agency.
A copy of the new form HUD-50058 is attached to this form. No other documentation is required. (Receiving PHAs are
required to complete and submit a form HUD-50058 for families moving into their jurisdiction under portability. The
receiving PHA may elect to conduct a special recertification of the family to conform the dates of the unit inspection and
recertification, but is not required to do so by HUD in order to complete the form HUD-50058 for a portability move-in.)
Go to line 9 below.
4. The HAP amount has changed effective ________________ (mm/dd/yyyy) for the family because of: (Check all applicable
items. A current copy of the form HUD-50058 must be attached to this form. No other documentation is required.)
Go to line 9 below.
____ annual recertification
____ interim/special recertification
____ change in payment standard
____ the family moved to another unit in the receiving PHA jurisdiction.
____ other:(specify)

Comments continued on separate page Yes
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form HUD-52665 (05/2004)
ref. Handbook 7420.8

5. The HAP payments: (Check one)
____ have been abated effective _______________ (mm/dd/yyyy).
Please suspend the HAP to owner portion from your payment effective _______________ (mm/dd/yyyy) until further notice.
____ that were abated beginning ________________ (mm/dd/yyyy) have been resumed
effective ________________ (mm/dd/yyyy).

6. We will no longer be billing your agency because we are terminating the family's participation in the program or the family
is voluntarily leaving the program.
Billing arrangement termination effective date:________________________ (mm/dd/yyyy)
Reason for termination:(specify)
7. We are absorbing the family into our program and terminating the billing arrangement effective: ____________________.
(mm/dd/yyyy)
8. The HAP contract has been terminated effective ___________________ (mm/dd/yyyy) and no new HAP contract has yet been
executed on behalf of the family.
The family:
____ will not be remaining in our jurisdiction and has been referred to your agency.
____ intends to remain in our jurisdiction. The family’s voucher expires _________________ (mm/dd/yyyy).
9. Billing Information
Regular Billing Amount
a. Monthly HAP amount due
(line 12s or 12af of form HUD-50058)

___________________

b. Ongoing admin fee (80% of initial PHA fee or
amount otherwise agreed upon) (line 10 of Part I of this form)

____________________

$0.00
____________________

c. Total regular monthly billing amount
(sum of lines a and b)

Additional Amount Due, If Applicable
d. Prorated HAP to owner from ____________to _____________

____________________

e. Hard-to-house fee

____________________

f. Other (explain)

____________________

g. Total additional amount (sum of lines d, e and f)

$0.00
____________________

Billing Amount

$0.00
____________________

h. Payment Due This Billing Submission (sum of lines c and g.)

(After this submission, billing amount is amount recorded on line c, unless otherwise notified by the receiving PHA.)

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form HUD-52665 (05/2004)
ref. Handbook 7420.8