HUD-52681 Financial Form

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

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

Voucher for Payment of
Annual Contributions
and Operating Statement
Housing Assistance Payments Program
See Instructions in appropriate program and books

Public reporting burden for this collection of information is estimated to average 1.50 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 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. Public Housing Agency (HA) (name and address)

2. Project Number

3. Annual Contributions Contract Number

4. Housing Program Type

Rental Certificate

Rental Voucher

Moderate Rehab.

Section 23

5. HA Fiscal Year Ending Date (mark one and complete the year as YYYY)

March 31, _____
6. Number of Unit Months under Lease by Bedroom Size: 1BR

7. Average Tenant Contribution

2BR

June 30, _____
3BR

4BR

Sept. 30, _____
5BR

December 31,_____
Other

8. Portability

Accounts Payable _________________________

Accounts Receivable ________________________

Request is hereby made for the payment of annual contributions pursuant to the terms and conditions of the above numbered Annual
Contributions Contract for the project and fiscal year shown above.
Part I. Request for Payment

Approved Budget Estimates
(a)

HA Actuals Total
(b)

HUD Approved Total
(c)

Maximum Annual Contributions Available
9. Maximum Annual Contributions Commitment (per ACC)
10. Prorata Maximum Annual Contributions applicable to a Period of less
than Twelve Months
11. Contingency Reserve, ACC Program Reserve
12. Total Annual Contributions Available (sum of lines 9, 10, and 11)
Annual Contributions Required
13. 4715
Housing Assistance Payments
14. Security and Utility Deposit Fund (Section 23 Only)
15. Ongoing Administrative Fees Earned
16. Hard-to-House Fees Earned (Rental Certificates, Rental Vouchers,
and Moderate Rehabilitation units converted to Rental Certificates)
17. Actual Independent Public Accountant Audit Costs
18. Total Preliminary Fees Earned
19. Total Funds Required (sum of lines 13 thru 18)
20. Deficit at End of Preceding Fiscal Year
21. Program Receipts Other than Annual Contributions (3610, 3690,
7530, and Section 23 Security and Utility Deposits Repaid)
22. Ongoing Fee Reduction
23. Total Annual Contributions Required
(line 19 plus line 20 minus line 21 minus line 22)

Previous editions are obsolete
Replaces form HUD-52681-A

Page 1 of 3

form HUD-52681 (02/2002)
ref Handbook 7420.8

Approved Budget Estimates
(a)

HA Actuals Total
(b)

HUD Approved Total
(c)

Balance of Annual Contributions Available
24. ACC Program Reserve Balance (Amount by which line 12 exceeds line 23)
25. Deficit (amount by which line 23 exceeds line 12)
26. Provision for ACC Program Reserve
a) Increase (Amount by which line 24 exceeds line 11)
b) Decrease (amount by which line 11 exceeds line 24)
Year End Settlement
27. Annual Contributions due for Fiscal Year (line 23 minus line 25)
28. Total Partial Payments Approved by HUD for Fiscal Year
29. Underpayment due HA (amount by which line 27 exceeds line 28)
30. Overpayment due HUD (amount by which line 28 exceeds line 27)
Part II. Operating Receipts
31. 3300
Interest Earned on Operating Reserve
32. 3300P Administrative Fee Income - Portable Certificates and Vouchers
33. 3610

Interest Earned on General Fund Investment

34. 3690

Other Income

35. 7530

Receipts from Non-Expendable Equipment not Replaced

36. Total Annual Contributions Required (line 23)
37. Total Receipts (sum of lines 31 thru 36)
Part III. Operating Expenditures
38. 4715
Housing Assistance Payments
39. Independent Public Accountant Costs (Section 8 only)
40. Total Ongoing Administrative Expenses
41. Total Preliminary Fees Earned
42. Total Expenditures (sum of lines 38 thru 41)
Prior Year Adjustments
43. Affecting Residual Receipts (or Deficit) for Debit (Credit)
44. Total Operating Expenses (line 42 plus line 43)
45. Net Income (or Deficit) before Provision for Operating Reserve
(line 37 minus line 44)

Previous editions are obsolete
Replaces form HUD-52681-A

Page 2 of 3

form HUD-52681 (02/2002)
ref Handbook 7420.8

Approved Budget Estimates
(a)

HA Actuals Total
(b)

HUD Approved Total
(c)

Part IV. Analysis of Operating Reserve
46. Operating Reserve - Balance at Beginning of FY Covered by this Statement
47. Cash Deposits to (or Withdrawals from) Operating Reserve During Fiscal Year
48. Net Income (or Deficit) before Provision for Operating Reserve (line 45)
Provision for Operating Reserve (Acct. 7016/Sec. 8; Acct. 7016.1/Rental Vouchers)
49. Addition (The amount of income, if any, on line 48)
50. Deduction (The amount of deficit, if any, on line 48)
51. Operating Reserve - Balance at End of Fiscal Year Covered by this
Statement (line 46 plus or minus line 47 plus line 49 or minus line 50)

I Certify that:
(1) housing assistance payments have been or will be made only in accordance with Housing Assistance Payments Contracts or Rental
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 voucher 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)
Name of Public Housing Agency

Title of Authorized HA Official

Signature of Authorized HA Official

Date (mm/dd/yyyy)

The Field Office has reviewed calculations of the Ongoing Administrative Fee. The HUD approved totals are the official totals as reported in HUD CAPs.
Name of Office

Signature of Director, Office of Public Housing

Date (mm/dd/yyyy)

Overpayment to be offset $ ____________________

Underpayment certified for payment to the HA $ ________________

Previous editions are obsolete
Replaces form HUD-52681-A

Page 3 of 3

form HUD-52681 (02/2002)
ref Handbook 7420.8