Hud 935.2

Appendix 1
Form HUD-935.2, Affirmative Fair
Housing Marketing Plan

OMB Approval No. 2529-0013
(exp. 09/30/2003)

U.S. Department of Housing
and Urban Development
Office of Fair Housing and Equal Opportunity

Affirmative Fair Housing
Marketing Plan

1a. Applicant's Name, Address (including city, state & zip code) & Phone Number

1c. Project/Application Number

1d. Number of Units

1e. Price or Rental Range
From $
To $

1f. For Multifamily Housing Only

Elderly

1g. Approximate Starting Dates (mm/dd/yyyy)

Non-Elderly

Advertising
Occupancy

1b. Project's Name, Location (including city, State and zip code)

1h. Housing Market Area

1i. Census Tract

1j. Managing/Sales Agent's Name & Address (including city, State and zip code)

2. Type of Affirmative Marketing Plan (mark only one)

Project Plan
Minority Area
White (non-minority) Area

3. Direction of Marketing Activity (Indicate which group(s) in the housing market area are least likely to apply for
the housing because of its location and other factors without
special outreach efforts)

White (non-Hispanic)

Hispanic

Black (non-Hispanic)

Asian or Pacific Islander

American Indian or Alaskan Native
Persons with Disabilities

Mixed Area (with ________ % minority residents)
4a. Marketing Program: Commercial Media (Check the type of media to be used to advertise the availability of this housing)

Newspapers/Publications

Radio

Name of Newspaper, Radio or TV Station

TV

Billboards

Other (specify)

Racial/Ethnic Identification of Readers/Audience

Size/Duration of Advertising

4b. Marketing Program: Brochures, Signs, and HUD's Fair Housing Poster

(1) Will brochures, letters, or handouts be used to advertise?
Yes
No If "Yes", attach a copy or submit when available.
(2) For project site sign, indicate sign size _______ x _______; Logotype size _______ x _______. Attach a photograph of project sign or submit when available.
(3) HUD's Fair Housing Poster must be conspicuously displayed wherever sales/rentals and showings take place. Fair Housing Posters will be displayed in
the

Sales/Rental Office

Real Estate Office

Model Unit

Other (specify)

4c. Community Contacts. To further inform the group(s) least likely to apply about the availability of the housing, the applicant agrees to establish and maintain
contact with the groups/organizations listed below that are located in the housing market area or SMSA. If more space is needed, attach an additional sheet.
Notify HUD-FHEO of any changes in this list. Attach a copy of correspondence to be mailed to these groups/organizations. (Provide all requested information.)
Name of Group/Organization

Racial/Ethnic
Identification

Address & Phone Number

Approximate Date
(mm/dd/yyyy)

Person Contacted or to be Contacted

Indicate the specific function the Group/Organization will undertake
in implementing the marketing program

Method of Contact

5. Future Marketing Activities (Rental Units Only) Mark the box(s) that best describe marketing 6. Experience and Staff Instructions (See instructions)
activities to fill vacancies as they occur after the project has been initially occupied.
6a. Staff has experience.
Yes
No
Newspapers/Publications
Radio
TV
Brochures/Leaflets/Handouts 6b. On separate sheets, indicate training to be provided to staff on Federal, State
and local fair housing laws and regulations, as well as this AFHM Plan. Attach
Site Signs
Community Contacts
Other(specify)
a copy of the instructions to staff regarding fair housing.
7. Additional Considerations Attach additional sheets as needed.

8. Changes and Revisions By signing this form, the applicant agrees, after
For HUD-Office of Housing Use Only
appropriate consultation with HUD, to change any part of the plan covering a
Approval By
Disapproval By
multifamily project to ensure continued compliance with Section 200.620 of Signature & Date (mm/dd/yyyy)
Signature & Date (mm/dd/yyyy)
HUD's Affirmative Fair Housing Marketing Regulations.
Signature of person submitting this Plan & Date of Submission (mm/dd/yyyy)

Name (type or print)

Name (type or print)

Name (type or print)

Title & Name of Company

Title

Title

Previous editions are obsolete

Page 1 of 2

ref. Handbook 8025.1

form HUD-935.2 (01/2001)

Public reporting burden for this collection of information is estimated to average 1 hour 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 collect
this information, and you are not required to complete this form, unless it displays a currently valid OMB control number.
The Affirmative Fair Housing Marketing Plan (AFHM) is needed to ensure that Federal agencies are taking necessary steps to eliminate discriminatory
practices involving Federally insured and assisted housing. No application for any housing project or subdivision insured or subsidized under the
Department’s housing programs can be funded without an approved AFHM Plan. The responses are required to obtain or retain a benefit under the Fair
Housing Act, Section 808(e)(5) & (6) and 24 CFR Part 200, Subpart M. The form contains no questions of a confidential nature.

Instructions

Send the Completed form to: Your Local HUD Office,
Attention: Director, Office of Housing
The Affirmative Fair Housing Marketing Regulations require that
each applicant subject to these regulations carry out an affirmative
program to attract prospective buyers or tenants of all minority and
non- minority groups in the housing market area regardless of race,
color, religion, sex, national origin, disability, or familial status.
These groups include Whites (Non-Hispanic), members of minority groups, i.e.., Blacks (Non-Hispanic), American Indians/Alaskan Natives, Hispanics, Asian/Pacific Islanders, persons with disabilities, or families with children in the Standard Metropolitan
Statistical Areas (SMSA) or housing market area who may be
subject to housing discrimination on the basis of race, color,
religion, sex, national origin, disability, or familial status. The
applicant shall describe on this form the activities it proposes to
carry out during advance marketing, where applicable, and the
initial sales rent-up period. The affirmative program also should
ensure that any group(s) of persons normally not likely to apply for
the housing without special outreach efforts (because of existing
neighborhood racial or ethnic patterns, location of housing in the
SMSA price or other factors), know about the housing, feel welcome to apply and have the opportunity to buy or rent.
Part 1 - Applicant and Project Identification. The applicant may
obtain Census Tract location information, item 1i, from local
planning agencies, public libraries and other sources of Census
Data. For item 1g, specify approximate starting date of marketing
activities to the groups targeted for special outreach and the
anticipated date of initial occupancy. Item 1j is to be completed
only if the applicant is not to implement the plan on its own.
Part 2 - Type of Affirmative Marketing Plan. Applicants for
multifamily projects are to submit a Project Plan which describes
the marketing program for the particular project or subdivision.
Scattered site builders are to submit individual annual plans based
on the racial composition of each type of census tract. For example,
if a builder plans to construct units in both minority and nonminority census tracts, separate plans shall be submitted for all of
the housing proposed for both types.
Part 3 - Direction of Marketing Activity. Considering factors such
as price or rental of housing, the racial/ethnic characteristics of the
neighborhood in which housing is (or is to be) located, the population within the housing market area, or the disability or familial
status of the eligible population, public transportation routes, etc.,
indicate which group(s) you believe are least likely to apply
without special outreach.
Part 4 - Marketing Program. The applicant shall describe the
marketing program to be used to attract all segments of the eligible
population, especially those groups designated in the Plan as least
likely to apply. The applicant shall state: the type of media to be
used, the names of newspapers/call letters of radio or TV stations;
the identity of the circulation or audience of the media identified in
Previous editions are obsolete

the Plan, e.g., White (Non-Hispanic), Black (Non-Hispanic), Hispanic, Asian-American/Pacific Islander, American Indian/ Alaskan Native; and the size or duration of newspaper advertising or
length and frequency of broadcast advertising. Community contacts include individuals or organizations that are well known in
the project area or the locality and that can influence persons within
groups considered least likely to apply. Such contacts may include, but need not be limited to: neighborhood, minority and
women's organizations, churches, labor unions, employers, public
and private agencies, disability advocates, and individuals who are
connected with these organizations and/or are well-known in the
community.
Part 5 - Future Marketing Activities. Self-Explanatory.
Part 6 - Experience and Staff Instructions.
a. Indicate whether the applicant has previous experience in marketing housing to group(s) identified as least likely to apply for
the housing.
b. Describe the instructions and training given to sales/rental staff.
This guidance to staff must include information regarding Federal, State and local fair housing laws and this AFHM Plan.
Copies of any written materials should be submitted with the
Plan, if such materials are available.
Part 7 - Additional Considerations. In this section describe other
efforts not mentioned previously which are planned to attract
persons in either those groups already identified in the Plan as least
likely to apply for the housing or in groups nor previously identified in the Plan. Such efforts may include outreach activities to
female-headed households and persons with disabilities.
Part 8 - The applicant's authorized agent signs and dates the
AFHM Plan. By signing the Plan, the applicant assumes full
responsibility for its implementation. The Department may at any
time monitor the implementation of the Plan and request modification in its format or content, where the Department deems necessary.
Notice of Intent to Begin Marketing. No later than 90 days prior
to the initiation of sales or rental marketing activities, the applicant
with an approved Affirmative Fair Housing Marketing Plan shall
submit notice of intent to begin marketing. The notification is
required by the Affirmative Fair Housing Marketing Plan Compliance Regulations (24 CFR Part 108.15). It is submitted either
orally or in writing to the FHEO Division of the appropriate HUD
Office serving the locality in which the proposed housing is
located. OMB approval of the Affirmative Fair Housing Plan
includes approval of this notification procedure as part of the Plan.
The burden hours for such notification are included in the total
designated for this Affirmative Fair Housing Marketing Plan form.

Page 2 of 2

ref. Handbook 8025.1

form HUD-935.2 (01/2001)

Appendix 2
Systematic Alien Verification for
Entitlements (SAVE) Program
Instructions Manual

Appendix 2

4350.3 REV-1

Appendix 2: Systematic Alien Verification for Entitlements (SAVE) Program
Instructions Manual
PREFACE
Appendix 2 is a copy of the User Manual created by The Immigration and Naturalization
Service in 2000 for the Systematic Alien Verification Entitlements (SAVE) Program. On
March 1, 2003 the Immigration and Naturalization Service (INS) was abolished and the
functions of INS became part of the Department of Homeland Security (DHS). Therefore
any reference in this manual to Immigration and Naturalization (INS) will now mean
Department of Homeland Security (DHS).
The Department of Homeland Security SAVE program Office in coordination with HUD
Headquarters provides authorized HUD users with the User access codes, Computer
Based Tutorial (CBT) and Quick Reference Guides needed to access the SAVE
database.
Questions or comments regarding this Manual or the SAVE Program should be directed
to the Department of Homeland Security, SAVE Program, ULLOCO Building, 425 I
Street, NW Washington, DC 20536, 202-514-2317.
Appendix A and Appendix F of the DHS SAVE User Manual are not included in
Appendix 2 of this Handbook. Form G-845 S, Appendix F, is Exhibit 4-2 of this
Handbook.

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Appendix 2

TABLE OF CONTENTS
TABLE OF CONTENTS

2

1. INTRODUCTION 3
1-1
Purpose and Scope ............................................................................................ 3
2. SAVE PROGRAM 5
2-1
Background......................................................................................................... 5
2-2
SAVE Legal Basis............................................................................................... 5
2-3
Program Components......................................................................................... 7
2-4
SAVE Program Administration.......................................................................... 10
2-5
General Verification Procedures....................................................................... 11
2-6
Legal Protection and Safeguards ..................................................................... 11
3. PRIMARY VERIFICATION PROCEDURES 14
3-1
Background....................................................................................................... 14
3-2
General Verification Procedures....................................................................... 14
3-3
Required Documentation .................................................................................. 14
3-4
Immediate Secondary Verification .................................................................... 16
3-5
ASVI Access Methods ...................................................................................... 16
3-6
Understanding ASVI Output Data..................................................................... 17
3-7
General Information .......................................................................................... 22
3-8
ASVI Enrollment Process ................................................................................. 22
4. LENGTH OF SERVICE
22
4-1
ASVI Billing Process ......................................................................................... 23
5. SECONDARY VERIFICATION PROCEDURES
24
5-1
Background....................................................................................................... 24
5-2
Initiating Secondary Verification ....................................................................... 24
5-3
Obtaining Secondary Verification ..................................................................... 25
5-4
Attachments...................................................................................................... 25
5-5
Completing the Document Verification Request ............................................... 26
5-6
Completing the Document Verification Request Supplement........................... 28
5-7
Mailing Document Verification Requests .......................................................... 28
5-8
Obtaining Copies of the Document Verification Requests and Supplement..... 29
5-9
Document Verification Request and Supplement Responses .......................... 29
5-10
Understanding the INS Response................................................................. 30
5-11
Delayed Replies ............................................................................................ 34
5-12
INS Record Keeping ..................................................................................... 35
Appendix A:
Appendix B:
Appendix C:
Appendix D:
Appendix E:
Appendix F:
Appendix G:
Appendix H:
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Sample Immigration Documents
Glossary
Hispanic Names
INS Office Locations
INS Office Addresses
Forms G845S, G845 and Supplement
INS Records Systems
Questions and Answers
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4350.3 REV-1

Introduction
Section 121 of the Immigration Reform and Control Act of 1986 (IRCA), as amended by
the Personal Responsibility and Work Opportunity Reconciliation Act of 1996
(PRWORA), requires verification of citizenship and immigration status of applicants
applying for many federal, state, and local public benefits. Each applicant for benefits
must declare in writing whether or not they are a citizen or national of the United States,
and if not, that they are in a satisfactory immigration status.
The Illegal Immigration Reform and Immigrant Responsibility Act of 1996 requires the
Immigration and Naturalization Service (INS) to respond to inquiries by federal, state,
and local benefit issuing agencies and institutions seeking to verify or determine the
citizenship or immigration status of any individuals within the jurisdiction of the agency
for any lawful purpose.
If an applicant or recipient for any of the benefits listed in IRCA, as amended, is not a
U.S. citizen or national, they must provide the benefit provider with documentation from
the INS that contains their Alien Registration Number (A-Number), or verbally provide
information from such documentation, that provides reasonable evidence of his or her
current immigration status. The INS verifies the immigration status through automated
and/or manual methods. The process of verification is known as the Systematic Alien
Verification for Entitlements (SAVE) Program.
The INS is currently using the SAVE automated and manual verification processes to
provide federal, state, and local benefit issuing agencies and institutions with information
which will assist them in determining an individual’s eligibility under Title IV of PRWORA.
1-1

Purpose and Scope

This manual describes the SAVE Program, including its legal basis, automated and
manual verification processes, and administrative procedures. Chapter 2 gives general
program guidelines and information on administration, and is designed for managers and
supervisors at benefit issuing agencies and institutions. Chapter 3 provides a detailed
overview of the primary verification process. Chapter 4 provides detailed instructions for
performing secondary verification. This manual serves as both a training and reference
guide for benefit providers and their managers.

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2. SAVE PROGRAM
This chapter of the Systematic Alien Verification for Entitlements (SAVE) Program
Manual describes the program and explains its legal basis and measures to safeguard
the rights of naturalized citizens and non-citizens.
Any questions or comments regarding this chapter of the manual should be directed to
the Immigration and Naturalization Service (INS) SAVE Program at (202) 514-2317.
2-1

Background

The SAVE Program is an intergovernmental information-sharing initiative designed to aid
benefit providers in verifying an applicant’s immigration status, thereby ensuring that
only entitled applicants receive public benefits. The INS SAVE Program provides an
information service for benefit issuing agencies and institutions. The INS does not make
determinations on any applicant’s eligibility for a specific benefit.
The SAVE Program has been in operation since 1987. Significant costs in claims for unentitled non-citizens have been avoided through benefit issuing agencies and
institutions’ participation in the SAVE Program.
2-2

SAVE Legal Basis

In 1986, Congress passed the Immigration Reform and Control Act of 1986 (IRCA),
which required INS to establish a system for verifying the immigration status of noncitizen applicants for, or recipients of, certain types of federally funded benefits, and to
make the system available to federal, state, and local benefit issuing agencies and
institutions that administer such benefits. The IRCA and the Personal Responsibility and
Work Opportunity Reconciliation Act of 1996 (PRWORA), mandates the following
programs and overseeing agencies to participate in the verification of an applicant’s
immigration status: the Temporary Assistance to Needy Families (TANF) Program, the
Medicaid Program, and certain Territorial Assistance Programs (U.S. Department of
Health and Human Services); the Unemployment Compensation Program (U.S.
Department of Labor); Title IV Educational Assistance Programs (U.S. Department of
Education); and certain Housing Assistance Programs (U.S. Department of Housing and
Urban Development).
The PRWORA created a very complex set of eligibility requirements that cannot be
easily summarized.
These requirements continue to be regularly amended by
Congress. The PRWORA did not affirmatively make any person eligible for any benefit.
Rather, it placed a new set of limitations on non-citizen eligibility on top of any preexisting program requirements (some of which may have limited non-citizen eligibility).
With certain exceptions, PRWORA made non-citizens who are not qualified aliens
ineligible for federal public benefits, and aliens who are not qualified aliens or lawful
non–immigrants or aliens paroled into the United States under Section 212(d)(5) of the
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Appendix 2

INA for less than one year ineligible for state or local public benefits. There are also
limitations on the eligibility of qualified aliens for benefits, again with exceptions. The
PRWORA, as amended by the Illegal Immigration Reform and Immigrant Responsibility
Act of 1996 (IIRIRA) and the Balanced Budget Act of 1997 (BBA), defines a “qualified
alien” as:
•
•
•
•
•
•
•
•

An alien who is lawfully admitted for permanent residence under the Immigration
and Nationality Act (INA)
An alien who is granted asylum under Section 208 of the INA
A refugee who is admitted to the United States under Section 207 of the INA
An alien who is paroled into the United States under Section 212(d)(5) of the INA
for a period of at least one year
An alien whose deportation is being withheld under Section 243(h) of the INA (as
in effect prior to April 1, 1997) or whose removal has been withheld under
Section 241(b)(3)
An alien who is granted conditional entry pursuant to Section 203(a)(7) of the INA
as in effect prior to April 1, 1980
An alien who is a Cuban/Haitian Entrant as defined by Section 501(e) of the
Refugee Education Assistance Act of 1980
Certain aliens who have been battered or subjected to extreme cruelty as defined
in USC Section 1641 (c)

The PRWORA restrictions do not apply to all federal, state, and locally funded activities
or programs; they apply only to non-exempted “federal public benefits” and “state and
local public benefits.” Therefore, benefit providers should first determine whether the
particular program they administer is providing a “federal public benefit” or a “state and
local public benefit” for which Title IV of PRWORA or other applied laws require alien
eligibility. For example, emergency medical care and certain forms of disaster relief are
exempt, as are other key benefits. If an agency requires further assistance in
determining whether a specific benefit it administers is a federal, state, or local public
benefit, it should contact the overseeing federal, state, or local Government agency, as
that agency would be in the best position to make that determination.
The PRWORA defines “federal public benefit” as:
•
•
•

Any grant, contract, loan, professional license, or commercial license provided by
an agency of the United States or by appropriated funds of the United States.
– AND –
Any retirement, welfare, disability, public or assisted housing, post-secondary
education, food assistance, unemployment benefit, or any other similar benefit
for which payments or assistance are provided to an individual, household, or
family eligibility unit by an agency of the United States or by appropriated funds
of the United States.

The PRWORA’s definition of “state and local public benefit” parallels the definition of
federal public benefit, except that it substitutes “state or local government” for “the
United States.” State or local public benefits do not include federal public benefits;
therefore, a benefit cannot meet both definitions. If a benefit qualifies as a “federal
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Urban Development

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4350.3 REV-1

public benefit,” it is not a “state or local public benefit” regardless of whether state or
local funding is also involved.
The IIRIRA requires INS to respond to inquiries by federal, state, and local benefit
issuing agencies and institutions seeking to verify or determine the citizenship or
immigration status of any individual within the jurisdiction of the agency for any lawful
purpose. The INS is currently using the SAVE Program’s automated and manual
verification processes to provide federal, state, and local benefit issuing agencies and
institutions with information which will assist them in determining an individual’s eligibility
under Title IV of PRWORA.
2-3

Program Components

As mandated by IRCA, INS developed an effective, secure, and cost effective method of
verification. The SAVE Program relies on the Alien Status Verification Index (ASVI)
database, which contains information on more than 60 million non-citizens. When
accessed by the user, ASVI responds within 3 to 5 seconds of the query. The ASVI
database is housed and maintained under contract with Lockheed Martin Integrated
Business Solutions (LMIBS). The automated process is known as the “primary
verification.” The following flow chart, Figure 2-1 shows the Primary Verification
Process.

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Appendix 2

Figure 2-1: Primary Verification Process

PRIMARY VERIFICATION PROCESS

Non-citizen submits
application to Benefit
Issuing Agency

PRIMARY VERIFICATION

SECONDARY VERIFICATION

Status Review and ASVI Query

Benefit Issuing Agency institutes
secondary verification process by
submitting completed Document
Verification Request, Form G-845,
with a photocopy of supporting
documentation or by submitting
additional information electronically
to appropriate INS field office for
thorough search of other INS
automated and manual data sources

NO
ASVI
Match?

YES
Benefit Issuing Agency
makes determination as to
applicant’s eligibility for
benefit

YES

INS either completes Form
G-845 or an electronic
response and replies to Benefit
Issuing Agency

NO

In most cases, Benefit Issuing Agencies that use primary verification will query ASVI
before instituting secondary verification.

In addition, SAVE verification is available through secondary verification if the use of
ASVI is not cost–effective. The SAVE Program also requires participating benefit
issuing agencies and institutions to use secondary verification when directed by an ASVI
system message during primary verification, or when the primary check or initial
inspection of a non-citizen’s immigration documentation reveals material discrepancies
or when verification of a naturalized citizen is required. See Figure 2-2 for a flow chart
on the Secondary Verification Process.

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4350.3 REV-1

Figure 2-2: Secondary Verification Process

SECONDARY VERIFICATION PROCESS
Non-citizen Submits
Application to Benefit Issuing
Agency
Agency Status Review

SECONDARY VERIFICATION
Benefit Issuing Agency institutes secondary
verification process by submitting completed
Document Verification Request, Form G-845, with a
photocopy of supporting documentation or by
submitting additional information electronically to
appropriate INS field office for thorough search of
other INS automated and manual data sources
INS either completes Form G-845 or an
electronic response and Replies to Benefit
Issuing Agency

Benefit Issuing Agency Makes
Determination as to Applicant’s
Eligibility for Benefit

YES

NO

Agencies that do not access ASVI will proceed directly to the secondary verification
process.

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2-4

Appendix 2

SAVE Program Administration

The SAVE Program is administered at the INS Headquarters Office in Washington, DC,
by the Office of Files and Forms Management, SAVE Program. User agencies and
institutions may contact INS SAVE Program staff at (202) 514-2317. The Data Systems
Division of the INS Office of Information Resources Management has responsibility for
providing technical support to the SAVE Program. The SAVE Program also provides
policy and guidance relating to the secondary verification process to INS field offices.
The INS Headquarters Office of Field Operations, Regional and District Offices, and
Suboffices have operational responsibility for carrying out policy and guidance provided
by the SAVE Program. Figure 2-3 is the INS organization chart as it relates to the SAVE
Program.

Figure 2-3: INS SAVE Program Organizational Chart

INS Commissioner

Executive Associate
Commissioner for
Field Operations

Regional Offices
- Coordination and liaison
with field Immigration
Status Verifiers (ISVs)
- Liaison with benefit
issuing agencies and
institutions

Executive Associate
Commissioner for
Management

Files and Forms
Management
SAVE Program
- Program responsibility
- Program development

District Offices and
Suboffices
- Secondary Verification
- Coordination and liaison
with counterparts in
benefit issuing agencies
and institutions

Information
Resources
Management

- Primary verification
policy and procedures

Data Systems
Division
- Primary database

- Secondary verification
policy and procedures

- Technical system
development and
maintenance

- Liaison with federal,
state, and local benefit
issuing agencies and
institutions

- Contracting Officer’s
Technical
Representative (COTR)
to LMIBS Contract

- Update of records

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Although IRCA, as amended by PRWORA, mandates only federal public benefit
programs to participate in SAVE, any federal, state, or local benefit issuing agency or
institution, or licensing issuing bureau that requires verification of a non-citizen’s
immigration status may inquire about participation by contacting the INS SAVE Program
at (202) 514-2317.
2-5

General Verification Procedures

At the time of application, all individuals applying for public benefits listed in IRCA and
PRWORA, are required to declare in writing, under penalty of perjury, whether they are a
United States citizen or a United States non-citizen national, or that they are in a
satisfactory immigration status. If an applicant claims to have a satisfactory immigration
status, they must present immigration documentation that the federal benefit provider is
required to verify with INS, or that the state and local benefit provider can opt to verify
with INS, via automated access to ASVI or through manual submission of a Document
Verification Request, or both.
Detailed instructions for the primary and secondary verification processes are located in
Chapters 3 and 4, respectively.
2-6

Legal Protection and Safeguards

Determination
of Benefits

Award or denial of a benefit based on immigration status and the
establishment of a fair hearing process are the responsibilities of the
benefit issuing agency or institution. The benefit issuing agency or
institution will obtain INS verification of immigration status, and
determine whether or not the non-citizen is eligible for a benefit
according to its own regulations.

Fair Hearing

Each benefit issuing agency or institution will maintain its own fair
hearing and appeals process for individuals who have been denied
benefits. The INS will provide the appropriate immigration technical
consultation and witness support necessary to the agency or
institution during the fair hearing process on a prearranged and
approved basis. The INS should be consulted well before the hearing
is scheduled to resolve any problems, such as data discrepancies or
misunderstandings that might have led to the denial.

Nondiscrimination

Various Federal civil rights laws and regulations prohibit
discrimination by governmental and private entities on the basis of
race, color, national origin, gender, religion, age, and disability. Thus
in operating or participating in a federally assisted program and
implementing the requirements of the INA, as amended by
PRWORA, including those described in this user’s manual, a benefit

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Appendix 2

issuing agency or institution should not, on the basis of race, color, or
national origin, directly or indirectly differentiate among persons in
the types of program services, aids, or benefits it provides or the
manner in which it provides them. For example, benefit providers
should treat all similarly situated individuals in the same manner, and
should not single out individuals who look or sound foreign for closer
scrutiny or require them to provide additional documentation of
citizenship or immigration status.
Certain data that is released during the verification process requires
Protection
Under Federal INS to comply with sections of the Privacy Act (5 U.S.C. 552a).
Consequently, INS will maintain a Record of Disclosure on all alien
Statutes
registration numbers checked through the verification process for legal
permanent residents (LPRs) and naturalized citizens. The following
data will be maintained regarding each query, and it will be disclosed
in accordance with the Privacy Act:
•
•
•
•

Alien registration number
Date and time of disclosure
Benefit issuing agency or institution requesting immigration status
verification
Non-citizen’s immigration status at the time of inquiry

The INS will protect an individual’s privacy to the maximum degree
possible, in accordance with the Immigration and Nationality Act and
any other applicable statutes.
If an immigration document does not contain an alien registration
number, INS will conduct computer checks against all available INS
data systems during manual verification to determine the holder’s
immigration status. The INS will make a record of disclosure when
all the following conditions hold true:
•
•
•

It finds that an alien registration number exists for that applicant;
The document appears bona fide; and
The non-citizen’s immigration status requires disclosure accounting.

The records of disclosure created by checks made against ASVI and
other systems of records will be available to any person or agency in
accordance with federal statutes.
The verification processes maintain an audit trail which is used for
purposes of identifying inordinate and extraordinary use of Alien
Registration Numbers. Examples of such suspicious activities include
non-existent Alien Registration Numbers and numbers checked
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repeatedly from multiple localities within a short period of time. This
information may be used by INS and other federal, state, and local law
enforcement entities for investigation of possible criminal activity, in
accordance with existing federal statutes. The ASVI audit trail will
not be used by INS for non–criminal, administrative enforcement of
immigration laws. Benefit issuing agencies or institutions that require
information from the audit trail should contact the INS SAVE
Program at (202) 514-2317.
Safeguards

The INS, participating benefit issuing agencies and institutions, and
contractors shall protect the individual’s rights to the fullest extent of
the law.
Immigration and Naturalization Service. The SAVE Program has
been implemented in a manner that provides for verification of
immigration status without regard to sex, color, race, religion, or
national origin of the individual involved. The INS stores information
in a secure area in order to safeguard its confidentiality. Data usage is
restricted to persons whose duties and responsibilities indicate a need
for its review.
Participating Benefit Issuing Agencies and Institutions.
Participating benefit issuing agencies and institutions shall provide a
non-citizen applicant with a reasonable opportunity to furnish
evidence of satisfactory immigration status. The benefit issuing
agency or institution using SAVE should make the determination for
itself whether benefits should be provided on an interim or temporary
basis to applicants pending completion of the SAVE processes,
applying any legal authority that may be relevant to that benefit. For
example, IRCA’s statutory provisions regarding Medicaid,
unemployment compensation, and other Federal benefit programs
required to use SAVE generally prohibit benefit issuing agencies and
institutions determining eligibility for these benefits from delaying,
denying, reducing, or terminating benefits pending SAVE verification.
Lockheed Martin Integrated Business Solutions (LMIBS). The
database housed and maintained by LMIBS is a “read only” system.
No update capability is available to the benefit providers. However, if
data discrepancies in ASVI are discovered during manual verification,
INS will update the database as necessary.
The LMIBS, under contract with INS, stores the database and
provides access to authorized benefit issuing agencies and institutions
using proper security safeguards. This system avoids dissemination of
applicant information to unauthorized individuals or agencies.

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Appendix 2

3. PRIMARY VERIFICATION PROCEDURES
This chapter of the SAVE Program manual provides instructions for primary verification.
It gives guidelines for evaluating non-citizen documentation, interpreting ASVI output,
and selecting cases for immediate manual verification when necessary.
Questions, comments, and changes regarding information in this section of the manual
should be directed to the INS SAVE Program at (202) 514-2317.
3-1

Background

SAVE Program participants will generally use the Alien Status Verification Index (ASVI)
database, which contains information on more than 60 million non-citizens for initial
automated status verification. This automated process is known as primary verification.
When accessed by the user, ASVI will respond within 3 to 5 seconds of the query.
Current users access the ASVI database, which is housed and maintained by Lockheed
Martin Integrated Business Solutions (LMIBS), with any one of six access methods.
Those methods of access include: 3270-terminal, Personal Computer, Point-of-Sale,
Touch-Tone Telephone, Electronic File Transfer, or Remote Job Entry. The touch-tone
telephone, point-of-sale, and electronic file transfer access methods are no longer
available to new users of the SAVE Program.
In addition, SAVE verification is available to benefit issuing agencies and institutions
through a manual verification process, known as secondary verification, when the use of
ASVI is not cost effective. Secondary verification is also required when primary
verification reveals material discrepancies or when the user is so directed by an ASVI
system message.
3-2

General Verification Procedures

At the time of application, all individuals applying for the public benefit programs listed in
the Immigration Reform and Control Act of 1986 (IRCA), as amended by the Personal
Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA), must
declare in writing, under penalty of perjury, that they are United States citizens or United
States non-citizen nationals and, if not, that they are in a satisfactory immigration status.
If an applicant is not a citizen or non-citizen national of the United States, they must
present immigration documentation that the benefit issuing agency or institution will
verify with INS, through the automated system or by submitting a Document Verification
Request, Form G-845, to INS.
3-3

Required Documentation

All non-citizens applying for public benefits must present immigration documentation, or
in some cases, verbally provide information from such documentation, that the benefit
issuing agency or institution determines is reasonable evidence indicating a satisfactory
immigration status. The document must be returned to the non-citizen by the reviewing
agency.

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If an applicant presents an expired document or is unable to present any immigration
documentation evidencing their immigration status, refer the applicant to the local INS
Office to obtain documentation of their immigration status. In unusual cases involving
applicants who are hospitalized or medically disabled, or who can otherwise show good
cause for their inability to present documentation, and for whom securing such
documentation would constitute an undue hardship, if the applicant can provide other
identifying documentation i.e., marriage records, court orders, etc., the benefit issuing
agency or institution may submit the Document Verification Request and, if applicable, a
copy of any expired INS document presented, to the local INS Office to verify the
applicant’s immigration status.
Section 264 of the Immigration and Nationality Act (INA), 8 U.S.C. 1304, states noncitizens 18 years of age or older in the United States must have immigration
documentation in their possession at all times. Non-citizens without documentation,
such as those who claim documents were lost or stolen, should be referred to the local
INS office (as shown in the U.S. Government listing of the telephone directory) to
request new documentation prior to the initiation of primary or manual verification
procedures.
Most non-citizen applicants will present documentation that contains an Alien
Registration Number (A-Number). This number references an individual’s non-citizen
file at INS. The A-Number contains seven, eight, or nine numerical digits preceded by
the letter A, e.g., A72 735 835. Each A-Number is unique in that it pertains to only one
person; even minors and infants who are not citizens or nationals of the United States
are assigned individual A-Numbers.
Immigration documentation includes but is not limited to the examples shown in
Appendix A of this manual. Except for the Arrival-Departure Record, Form I-94, such
documents should show the A-Number of the bearer. Some documents have expiration
dates. These dates should be checked during the benefit issuing agency or institution’s
visual examination of the documentation. Some forms have been released in several
editions and, therefore, valid documentation may not match the example exactly. The
examples in Appendix A represent those INS documents that are most commonly
presented and are not all inclusive. Appendix B-Glossary, defines terms related to
immigration status.
A Form I-94 with the following endorsement will have an A-Number annotated on it and
is an acceptable document as long as the expiration date has not passed: “Processed
for I-551. Temporary Evidence of Lawful Admission for Permanent Residence. Valid
until ___________. Employment Authorized or Temporary Form I-551, Admission for
permanent resident or (port) (date) verified.” A non-citizen’s passport may also contain
the endorsement above and will have an A-Number annotated on the passport.
Non-citizens also may present other pertinent documents, such as marriage records or
court orders, that indicate the identity or United States residency of the holder. Although
these documents may not serve as adequate proof of immigration status, they may
prove useful in the secondary verification process, when required.
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Appendix 2

Some INS documents do not contain a photograph of the bearer. When such
documentation is presented, INS strongly recommends that the benefit provider ask for a
document that includes a photograph, such as a driver’s license or an employee badge.
A copy of this document need not be provided during the secondary verification process
because the purpose of requesting the document is to ensure that the benefit provider
can identify the non-citizen satisfactorily.
3-4

Immediate Secondary Verification

Under most circumstances, an automated check of INS records through ASVI is the first
step in the verification process. However, the following circumstances require that the
benefit provider forego the use of ASVI and perform secondary verification immediately:
• A document appears to be counterfeit or altered. Characteristics of suspect
documentation include photograph substitution and ink discoloration.
• A non-citizen presents unfamiliar INS documentation, or a document that
indicates immigration status, but does not contain an A-Number.
• A non-citizen presents immigration documentation with an A-Number in the
60,000,000 or 80,000,000 series.
• The non-citizen has no immigration documentation and is hospitalized, medically
disabled, or who can otherwise show good cause for their inability to present
documentation, and for whom securing such documentation would constitute an
undue hardship.
• The non-citizen presents a foreign passport and/or Form I-94 and the “Admission
for Permanent Residence” endorsement is more than 1 year old.
• The applicant presents a Certificate of Naturalization or a Certificate of
Citizenship, and verification of U.S. citizen status is required.
•
If a non-citizen applicant presents any of the above immigration documentation to the
benefit issuing agency or institution, photocopies should be submitted immediately to
INS with a completed Document Verification Request for secondary verification. See
Chapter 4 of this manual for instructions on submitting a secondary verification request
to INS.
3-5

ASVI Access Methods

Current users access the ASVI database with any one of six access methods. Those
methods of access include:
• 3270-type terminal, or personal computer with 3270 emulation board, using a
dedicated telecommunications line (interactive access, monitor, and printer)
• Personal computer (PC) or teletype terminal, using a standard telephone
(asynchronous) line (interactive access, monitor and printer)
• Point-of-sale (POS) emulation (interactive access, PC, and printer)
• Touch-tone telephone or standard dial telephone with tone generator (interactive
access, voice data response)
• Electronic file transfer (EFT) using personal computer with communications
software, via a standard telephone or dedicated telecommunications line (batch
access, monitor, and printer)
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Remote job entry (RJE) terminal, or personal computer with RJE emulation
board, using a standard telephone or dedicated telecommunications line (batch
access, monitor and printer)

The touch-tone telephone, point-of-sale, and electronic file transfer access methods are
no longer available to new users of the SAVE Program. Contact the INS SAVE Program
at (202)514-2317 to obtain step-by-step instructions for accessing ASVI via any of the
other methods listed above.
3-6

Understanding ASVI Output Data

The data fields contained in the display or voice output response for most ASVI users
are illustrated in Figure 3-1.
Benefit providers should compare data on the documentation to the corresponding fields
in ASVI. The biographical data and status information in ASVI must correspond to the
data on the documentation. If the benefit provider determines that discrepancies exist,
he or she should initiate the secondary verification process, as instructed in Chapter 4.
Secondary verification must also be initiated when ASVI returns the message “Institute
Secondary Verification.”

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Appendix 2

Figure 3-1: ASVI Output Data Fields

1
2
3
4
5
6
7
8
9
10

IMMIGRATION AND NATURALIZATION SERVICE ALIEN
STATUS VERIFICATION INDEX DISPLAY
PLEASE ENTER THE ALIEN NUMBER
ALIEN NUMBER

:

LAST NAME

:

FIRST NAME

:

DATE OF BIRTH

:

COUNTRY OF BIRTH

:

ALTERNATE ID

:

SSN

:

DATE OF ENTRY

:

INS STATUS

:

VERIFICATION NUMBER

:

PF1 EXIT

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PF5 HELP

(MMDDYYYY)

(MMDDYYYY)

PF9 VERIFICATION INSTRUCTIONS

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The following is provided to assist benefit issuing agencies and institutions in
understanding the data output fields provided by ASVI:
Table 1

Field
1. Alien Number

Explanation
An A-Number is a seven, eight, or nine-digit number
referencing an actual paper file, known as the Alien File,
relating to an individual. Each A-Number is unique in
that it pertains to a single person; even infant and minor
non-citizens are assigned individual A-Numbers.
When entering an A-Number into ASVI, nine digits are
required. If the A-Number is less than nine digits, add
leading zeros. Do not enter the “A” in any case.
Examples:

2. Last Name

A9 735 832 - enter as 009735832
A72 735 835
- enter as 072735835
A999 999 999 - enter as 999999999
Hispanic surnames may include as many as four names,
e.g., Rivera Gonzales de Cuervo. In some cases,
applicants may hyphenate parts of the surname, e.g.,
Rivera-Gonzales de Cuervo, whereas the database
seldom uses the hyphenated format. Some non-citizens
may be registered under abbreviated or Anglicized
versions of their names. ASVI also may give transposed
versions of names, e.g., de Cuervo Rivera Gonzales.
Refer to Appendix C for a more detailed explanation of
Hispanic Names.

In Asian cultures, the surname frequently is written before the
given name. The names of non-citizens from such cultures
may be recorded in transposed order in INS files.
In the case of a recent marriage, the non-citizen may not have
yet furnished the new name to INS. Hence, ASVI may not
reflect the name change.
First Name

Many Hispanic first names consist of more than one
word, for example, Maria de los Angeles. Connecting
prepositions and articles such as “de la” may not have
been recorded properly in INS records.

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Field
3. Date of Birth

4. Country of Birth

5. Alternate ID

6. Social Security
Number (SSN)

Appendix 2

Explanation
Occasionally, the month and day elements of the birth
date may be transposed in the ASVI database or on a
non-citizen’s application for benefit. The INS registers
the date of birth by month, day, and year using format
MMDDYYYY, e.g., 01041957 is January 4, 1957. Some
cultures record dates as day, month, and year using
format DDMMYYYY, e.g., 01041957 is April 1, 1957. A
non-citizen may continue to provide dates in this fashion.
With certain access methods, only the first five letters of
the name of the country of birth will be given in the ASVI
response. In the case of Austria and Australia, however,
only the last five letters of the country of birth would be
shown in an abbreviated version of the country name.
A non-citizen’s country of birth is not necessarily their
country of nationality, i.e., the country to which they owe
allegiance.
If a non-citizen also has an Admission Number (Number
issued to a non-citizen on an Arrival-Departure Record,
Form I-94), it will be displayed in this field. Querying
ASVI by the Admission Number is also available to
benefit issuing agencies and institutions if there is a
reasonable need and accessing ASVI by this number is
found feasible by the INS SAVE Program.
INS records currently do not contain a Social Security
Number for every non-citizen on file. When the SSN is
available, ASVI will announce the SSN, for touch-tone
telephone access, or will fill the display field with the SSN
for other access methods.

7. Date of Entry

This date represents the non-citizen’s most recent entry
into the United States or the date his or her status was
adjusted to a lawful permanent resident. The INS uses
numeric representation in the format MMDDYYYY.

8. INS Status

INS has over 650 alphanumeric codes that identify a
non-citizen’s immigration status.
ASVI displays or
announces one of these codes when a query is
performed. The codes are categorized into six groups
that correspond to interpretative messages listed in item
number 10 below.
Benefit issuing agencies and
institutions can obtain a description of INS codes of
admission by contacting the INS SAVE Program.

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Field
9. Verification
Number

10. ASVI System
Message/Employ
ment Eligibility
Statement

4350.3 REV-1

Explanation
The system will provide a unique verification number with
the output from every query. This number will contain
information that identifies the query. Users should
always record this number in the applicant’s file for both
quality assurance and ease in processing Freedom of
Information Act requests.
This message helps the benefit-issuing agency or
institution verify that a non-citizen’s immigration status is
valid or if a secondary verification is required. It also
provides employment eligibility information. Most users
will receive one of the seven messages listed below:
•
•
•
•
•
•
•
•

Lawful Permanent Resident - Employment Authorized
Refugee - Employment Authorized
Asylee – Employment Authorized
Cuban/Haitian Entrant - Temporary Employment
Authorized
Section 245A Temporary Resident - Temporary
Employment Authorized
Section 210 Temporary Resident - Temporary
Employment Authorized
Application Pending - Temporary Employment
Authorized
Institute Secondary Verification

If one of the first six messages is received, normal user
agency procedures for issuing benefits may continue.
The seventh message, “Institute Secondary Verification,”
requires further inquiry into INS records. When this
message appears, manual verification procedures, as
described in Chapter 4, should be followed.

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3-7

General Information

System Hours
Technical
Assistance

Program
Assistance

3-8

Appendix 2

The ASVI database is available for interactive queries between 7:00
a.m. Eastern Standard Time (EST), and 8:00 p.m. Pacific Standard
Time (PST), Monday through Friday.
Users should call the Customer Service Help Desk regarding
technical problems with the ASVI System such as inability to access
the system, exceptionally slow response times, and system failures.
The Customer Service Help Desk provides support Monday through
Friday, 8:00 a.m. EST to 8:00 p.m EST via its toll-free telephone
number, 1-800-467-0375.
The INS SAVE Program will answer questions regarding program
policies and enrollment procedures. Personnel are available from
7:30 a.m. EST to 5:00 p.m. EST, Monday through Friday, at
(202) 514-2317.

ASVI Enrollment Process

After a benefit issuing agency or institution expresses interest and receives approval
from INS to participate in the SAVE Program, the procedures below should be followed:

Step
1.

Action
The benefit issuing agency or institution determines the best access
method to meet their needs in light of the size and scope of the estimated
non-citizen population. The INS SAVE Program can provide assistance
in this area.

2.

A Memorandum of Understanding (MOU) is formalized with INS. An
example of suggested language for a MOU is available from the INS
SAVE Program.

3.

The benefit issuing agency or institution prepares a purchase order for
teleprocessing services based on estimated usage and access method
selected, and mails it to the INS contractor at the following address:
Lockheed Martin Integrated Business Solutions, 12506 Lake Underhill
Road, MP-266, ATTN: Kim Pearson, Contracts Administrator, Orlando,
FL 32825-5002. Each benefit issuing agency or institution should
prepare a purchase order form that is used within each respective office.
The purchase order should contain the following information:
4.
LENGTH OF SERVICE
Obligated dollar amount
Citation of INS contract number
Original signature of appropriate representative
Each benefit issuing agency or institution must complete a new purchase

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4.

Action
order form each fiscal year (by October 1) in order to continue accessing
the ASVI database.
The contractor enrolls the benefit issuing agency or institution in the
SAVE Program and assigns an account number. Appropriate user
identification numbers, authorization codes, and instructions for
accessing the ASVI database are provided at this time.

5.

The benefit issuing agency or institution accesses the ASVI database.

Step

4-1

ASVI Billing Process

The following are billing procedures:

Step
1.

Action
The agency or institution accesses ASVI with a unique user identification
number.

2.

The contractor collects usage data.

3.

The contractor prepares the billing.

4.

The contractor sends the invoice to the benefit issuing agency or institution’s
resource accounting division.

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Appendix 2

5. SECONDARY VERIFICATION PROCEDURES
This chapter of the SAVE Program Manual provides instructions for secondary
verification, for both the Alien Status Verification Index (ASVI) and non-ASVI user. It
gives guidelines for initiating secondary verification and understanding INS’ response to
the verification request.
Questions and comments regarding secondary verification should be directed to the INS
SAVE Program at (202)-514-2317.
5-1

Background

The SAVE Program requires participating agencies and institutions to submit secondary
verification requests to the INS under specified circumstances. The INS conducts
thorough searches of applicable INS databases and paper files, as necessary, to
respond to such secondary verification requests. A combination of both the primary and
secondary components of the SAVE Program are used by a large number of SAVE
users. However, status verification involving only the secondary process is available to
benefit issuing agencies and institutions that have a very small number of non-citizen
applicants for benefits.
The purpose of the secondary verification process is two-fold. First, it allows agencies to
participate in the SAVE Program when access to the automated system would not be
cost effective. Second, it provides a thorough search of all applicable INS automated
databases and paper files when questions arise during the visual verification of
documentation or the primary verification.
5-2

Initiating Secondary Verification

Benefit issuing agencies and institutions with access to ASVI will perform primary
verification for most non-citizen applicants prior to initiating secondary verification
procedures. However, certain circumstances require that the benefit provider forego the
use of ASVI and perform secondary verification immediately. Refer to the “Immediate
Secondary Verification” topic in Chapter 3 for circumstances that require immediate
secondary verification. Additionally, secondary verification should occur after an
automated ASVI check when:
• ASVI returns a response of “Institute Secondary Verification”
• A material discrepancy between an applicant’s immigration documentation and
the record contained in ASVI exists
• A non-citizen claims they obtained Lawful Permanent (or Conditional) Resident
Status because they were a battered alien, a parent of a battered child(ren), or a
victim of domestic violence. Refer to the Interim Guidance on Verification of
Citizenship, Qualified Alien Status, and Eligibility Under Title IV of the Personal
Responsibility and Work Opportunity Reconciliation Act of 1996, 62 FR 61344 at
Exhibit B to Attachment 5 (Nov. 17, 1997), for instructions on verifying noncitizens claiming status in this category.
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Sponsorship information from the non-citizen’s Affidavit of Support (Form I-864)
is required
Obtaining Secondary Verification

To obtain secondary verification, the benefit provider will forward a completed Document
Verification Request with fully readable photocopies of both sides of the non-citizen’s
immigration documentation to their local INS Office for review. The INS Offices are
listed by state and county in Appendix D; their addresses are given in Appendix E.
Benefit issuing agencies and institutions mandated by the Immigration Reform and
Control Act of 1986 (IRCA) to participate in the SAVE Program are required to use Form
G-845S, Document Verification Request and all other participating benefit issuing
agencies and institutions must use Form G-845, Document Verification Request. The
Document Verification Request Supplement, Form G-845 Supplement, can be used in
conjunction with both forms, but not separately to obtain additional immigration
information required to make a determination for benefit eligibility as a result of the
PRWORA, as amended. These forms are included in Appendix F and can be copied by
benefit issuing agencies and institutions for use in instituting secondary verification.
A separate Document Verification Request should be completed for each applicant and
should include copies of the documents for that person only. If a family unit has applied
for a benefit, each member will require a separate Document Verification Request.
5-4

Attachments

A photocopy of all applicable printed pages of each piece of immigration documentation
presented should be attached to the Document Verification Request. The INS requires
that benefit issuing agencies and institutions copy all printed sides of each INS-issued
card or form presented. When the non-citizen presents a foreign passport as
documentation, INS only requires copies of those pages that identify the issuing country,
holder, and immigration status while in the United States (i.e., Form I-94 INS stamp).
If the applicant presents expired immigration documents or is unable to present any
immigration documentation evidencing his or her immigration status, the benefit issuing
agency or institution should refer the applicant to the local INS office to obtain
documentation of status. In unusual cases involving applicants who are hospitalized or
medically disabled, or who can otherwise show good cause for their inability to present
documentation, and for whom securing such documentation would constitute an undue
hardship, if the applicant can provide other identifying documentation i.e., marriage
records, court orders, etc., the benefit issuing agency or institution may file the
Document Verification Request, and, if applicable, copies of any expired INS documents
presented, with the local INS office to verify immigration status. As with any
documentation of immigration status, the benefit issuing agency or institution should
confirm that the status information received from INS pertains to the applicant whose
identity has been verified.
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Appendix 2

Although an INS document is all the identification required to complete the secondary
verification request, the attachments may include identification bearing a photograph of
the applicant. If the non-citizen has presented another pertinent document, such as a
marriage record or court order, it may be included as well. Refer to Appendix A for
examples of commonly presented INS documentation. Note that other INS forms can
serve as valid identification documents.
The name and address of the benefit issuing agency or institution submitting the
Document Verification Request should be typed or stamped in the block labeled “From.”
The INS office address the Document Verification Request is being sent to should be
typed or stamped in the block labeled “To.”
5-5

Completing the Document Verification Request

The Document Verification Requests (Form G-845S and Form G-845) (see Appendix F)
should be completed as fully as possible by the submitting agency. It is essential that
the form contain sufficient information to verify the immigration status of the non-citizen.
The benefit issuing agency or institution completes Section A.
The following chart provides instructions for completing Section A of Form G-845S and
Form G-845.
Table 2

Field
1.Alien Registration
Number or I-94
Number

Instructions
Enter the alien registration number as the letter A
followed by a series of seven, eight, or nine digits.
The admission number found on the Form I-94
consists of eleven digits and is found at the upper
left–hand corner of the form. It may assist in the
various
searches
made
during
secondary
verification.

2. Applicant’s Name

Enter last, first, and middle name of applicant. If
documentation indicates more than one variation of
the name, enter all versions. Appendix C provides
information on Hispanic names.

3. Nationality

Enter the foreign nation or country to which the
applicant owes allegiance. This is normally, but not
always, the country of birth.

4. Date of Birth

Enter the birth date using the MM/DD/YYYY format.
If the complete date of birth is not known, give
available information.

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Field
5. Social Security
Number

Instructions
Enter the non-citizen’s nine-digit Social Security
number, if known. Copy the number directly from
the non-citizen’s Social Security card whenever
possible.

6. Verification Number

Enter the verification number assigned when ASVI
was queried, if applicable. If ASVI was not queried,
enter “none.”

7. Photocopy of
Document Attached
and Other
Information
Attached

Indicate that INS documentation is attached by
checking the top box. Use the bottom box if other
information has been included in support or in lieu of
INS documents.

8. Benefit/Your Case
Number

If completing the Form G-845S, mark the blocks
showing the benefit program(s) for which the noncitizen has applied. If completing the Form G-845,
enter the benefit program(s) for which the non-citizen
has applied. This block may also be used to show
the benefit issuing agency’s or institution’s case
number.
The name of the submitting official from the benefit
issuing agency or institution should be entered.

9. Name of Submitting
Official
10. Title of Submitting
Official
11. Date
12. Telephone Number

The title of the submitting official from the benefit
issuing agency or institution should be entered.
The date the Document Verification Request is being
completed by the submitting official from the benefit
issuing agency or institution should be entered.
The telephone number that the Immigration Status
Verifier can contact the submitting official from the
benefit issuing agency or institution, if necessary,
should be entered

The name and address of the benefit issuing agency or institution submitting the
Document Verification Request should be typed or stamped in the box labeled “From.”
The INS office address the Document Verification Request is being sent to should be
typed or stamped and the box labeled “To.”

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5-6

Appendix 2

Completing the Document Verification Request Supplement

The Document Verification Request Supplement (G-845 Supplement) (See Appendix F)
may only be used in conjunction with the Document Verification Request (Form G-845S
or Form G-845), not separately. It should also be completed as fully as possible by the
benefit issuing agency or institution. The following information should be provided on
Form G-845 Supplement by the benefit issuing agency or institution.
•
•
•
•
•
•

Non-citizen applicant’s last, first, and middle name;
Social Security Number (if available);
Alien Registration Number (A-Number) and/or I-94 Number;
Typed or stamped name and address of submitting agency;
Current date;
Submitting agency’s telephone number.

Refer to the “Completing the Document Verification Request” topic in this Section for
more detailed instructions on providing this information.
The benefit issuing agency or institution should indicate what status information is
required from INS by checking off the appropriate numbered block9s) in the “Complete
the following items:” section on the top portion of the Form G-845 Supplement. It is very
important that the benefit issuing agency or institution complete this section, so that INS
can provide all appropriate INS status information required to make a determination
regarding the applicant’s eligibility for benefits under Title IV of PRWORA, as amended.
The following INS information can be obtained by submitting Form G-845 Supplement:
1.
2.
3.
4.
5.
6.
7.
5-7

Immigration status;
Date alien entered the United States;
Date status was granted;
Date status expires;
Citizen status;
Special benefit provisions for certain victims of abuse; and
Affidavit of Support.

Mailing Document Verification Requests

Photocopies of documentation should be stapled to the Document Verification Request
with a single staple in the upper left-hand corner. The form and documents can be
folded and placed in a window envelope, with the block labeled “To” showing in the
address area. More than one G-845 can be mailed in a single envelope; however, INS
discourages benefit issuing agencies and institutions from collecting forms over an
extended period of time in order to mail them in bulk.
All benefit issuing agencies and institutions should mail Form G-845 to their local INS
Office. The notation, “ATTN: Immigration Status Verifier,” should be included on the
envelope to ensure proper handling by the INS mailroom. Immigration Status Verifiers
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(ISVs) are located in INS Offices throughout the United States, Puerto Rico, Virgin
Islands, and Guam. To determine the correct INS Office, review the list of states and
counties in Appendix D; their mailing addresses are included in Appendix F.
5-8

Obtaining Copies of the Document Verification Requests and Supplement

Benefit issuing agencies and institutions may duplicate the Document Verification
Requests and Supplement provided in Appendix F; both forms should be reproduced as
two-sided documents. Additional copies of the forms may also be obtained as follows:
1. Request Document Verification Request (Form G-845S and Form G-845) and the
Document Verification Supplement (Form G-845 Supplement) from the INS Form
Distribution Center serving your region as noted below:
East of the Mississippi River:

Eastern Forms Center
P.O. Box 567
Williston, VT 05497

West of the Mississippi River:

Forms Center West
5600 Rickenbacker Road
Building 701A
Bell, CA 90201

2. Download the Document Verification Requests and Supplement from the Internet:
www.usdoj.gov/ins/forms.
3. Call the INS Forms Request Line: 1-800-870-3676. (Due to the high volume of calls
to this line, the best time to call is early on weekday mornings.)
5-9

Document Verification Request and Supplement Responses

Immigration Status Verifiers (ISVs) will research the non-citizen applicant’s records in
INS automated databases and paper files, complete the response portion, Section B, of
the Document Verification Request, and return both the form and attached photocopies
to the requesting agency within ten working days of receipt by the local INS Office for
mandated benefit issuing agencies and institutions, and within the timeframe specified in
the Memorandum of Understanding (MOU) for all other benefit issuing agencies and
institutions.
The secondary verification process includes the following:
•
•
•
•
•
•

Examination of the photocopies of the immigration documentation
Search of all applicable INS records systems (both automated and manual)
Review of the applicant’s Alien File (A-File), if required
Evaluation of findings
Determination of immigration status
Return Form G-845 to benefit issuing agency or institution

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Appendix 2

Automated INS databases and paper files that may be used include:
•
•
•
•
•
•
•
•

Central Index System (CIS) — The most complete online record of non-citizens
and naturalized citizens in the United States
Non–immigrant Information System (NIIS) — An automated database that
contains information on non-immigrants, such as visitors and foreign government
officials
Computer-Linked Application Information Management System (CLAIMS) - A
national automated database that records and tracks cases for immigration
benefits
Students/Schools System (STSC) — The online file of foreign students in U.S.
academic and vocational educational institutions
Deportable Alien Control System (DACS) - An automated database that records
activities associated with aliens who are detained or placed under docket control
for deportation or exclusion
Alien Files — The paper files on non-citizens in the United States
INS Microfilm Files — Files containing pre-CIS records
Federal Records Center Index — Resource used to access retired government
records

A description of each of these sources is located in Appendix G.
5-10

Understanding the INS Response

The Document Verification Request and Supplement are self-reply forms. The ISV will
check all appropriate statements on the lower half and back of the Document Verification
Request, and, if applicable, on the lower half and back of the Document Verification
Request Supplement, to indicate the applicant’s immigration status and work eligibility.
Statements on the front of the Document Verification Request are interpreted as follows:
Table 3

Block
1. This document
appears valid and
relates to a Lawful
Permanent
Resident alien of
the United States

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Explanation
Checked when the documentation submitted is
determined to be a valid Form I-551, or a valid Form
I-94, with the notation “Processed for I-551,
Temporary Evidence of Lawful Admission for
Permanent Residence.” (The term temporary here
refers to documentary evidence. It is not intended to
imply that the immigration status itself is temporary.)
Immigration law allows this person to live and work
in the United States on a permanent basis.

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Block
2. This document
appears valid and
relates to a
Conditional
Resident alien of the
United States

3. This document
appears valid and
relates to an alien
authorized
employment as
indicated below:
4. This document
appears valid and
relates to an alien
who has an
application pending
for:
5. This document
relates to an alien
having been
granted
asylum/refugee
status in the United
States.

6. This document
appears valid and
relates to an alien
paroled into the
United States
pursuant to Section
212 of the INA
7. This document

4350.3 REV-1

Explanation
Checked when the documentation submitted is
determined to be a valid Form I-94 stamped with the
notation Processed for I-551, “Temporary Evidence
of Lawful Admission for Permanent Residence,” or a
valid Form I-551. Under the law, this person is
allowed to live and work in the United States.
However, INS will reevaluate his or her status within
2 years. Conditional resident non-citizen status is
normally granted to non-citizens that marry U.S.
citizens or nationals, or lawful permanent resident
non-citizens of the United States.
Checked to indicate if the authorization covers fulltime or part-time employment and when, if
applicable, the period of employment will expire.
“Indefinite” will be indicated if there is no specific
expiration date for employment eligibility.
Checked when a non-citizen’s application for a new
immigration status or change of immigration status is
pending. If a change of status is pending, the
appropriate block indicating the current status will
also be checked. (When an application is pending, it
means that a determination has not yet been made
by the INS.)
Checked when a non-citizen has been granted
asylee or refugee status in the United States,
because of persecution or a well-founded fear of
persecution in his or her country of nationality.
These statuses are considered temporary.
Documentation presented may include Form I-94,
Stamped with “Section 207—Refugee” or “Section
208—Asylee” or a Form I-571, Refugee Travel
Document.
Checked for a non-citizen who has been allowed to
enter the United States under emergency conditions
or when his or her entry has been determined to be
in the public interest. This status is temporary.
Documentation presented may include Form I-94,
stamped with “Section 212(d)(5) – Parolee.”
Checked for Cubans who entered the United States

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Appendix 2

Block
appears valid and
relates to an alien
who is a
Cuban/Haitian
entrant

Explanation
between April 15, 1980, and October 10, 1980, and
Haitian who entered the country before January 1,
1981. This is a temporary status. Documentation
presented may include Form I-94, stamped
Cuban/Haitian Entrant. This status is covered by
Section 501(e) of the Refugee Education Assistance
Act of 1980, as amended.
8. This document
This category of non-citizens was originally defined
by Section 203(a)(7) of the INA but was abolished by
appears valid and
the Refugee Act of 1980. The INS no longer
relates to an alien
who is a conditional provides benefit issuing agencies and institutions
with this response.
entrant
9. This document
Checked to indicate a non-citizen who is temporarily
in the United States for a specific purpose. This
appears valid and
category includes students, visitors, and foreign
relates to an alien
government officials. Documentation presented may
who is a
include Form I-94.
nonimmigrant
10. This document
Checked when a non-citizen’s status prohibits
employment in the United States.
appears valid and
relates to an alien
not authorized
employment in the
United States
11. Continue to
Checked if INS will withhold judgment regarding the
status or validity of documentation pending further
process as legal
investigation. This statement does not imply that the
alien. INS is
applicant is an illegal non-citizen or the holder of
searching indices
fraudulent documentation. The non-citizen should be
for further
presumed eligible while INS’ final notification
information
regarding immigration status is pending.
12. This document is
Checked for expired documentation or when the
documentation appears to be counterfeit or altered.
not valid because
If necessary, the ISV will use the back of the Form
it appears to be:
G-845 to elaborate on this entry. When the entries
for counterfeit or altered documents are checked, the
requesting agency or institution should follow its own
guidelines for investigating and prosecuting cases of
fraudulent documentation.
The Comments block on the second page of the Document Verification
Request is used to provide the benefit provider with further instruction. It
includes the following statements:
13. No determination
Checked when the benefit issuing agency or
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Block
can be made from
the information
submitted. Please
obtain a copy of
the original alien
registration
documentation and
resubmit.
14. No determination
can be made
without seeing
both sides of the
document
submitted (please
resubmit request)

Explanation
institution is required to resubmit the Document
Verification Request with copies of both sides of the
original immigration documentation presented by the
non-citizen applicant.

15. Copy of document is
not readable (please
resubmit request)

Checked when the benefit issuing agency or
institution is required to resubmit the Document
Verification Request with higher quality copies of the
original immigration documentation presented by the
non-citizen applicant.

Checked when the benefit issuing agency or
institution is required to resubmit the Document
Verification Request with copies of all sides of each
document presented by the non-citizen applicant.

Blocks 16 and 17 were originally designed to assist benefit issuing agencies and
institutions in determining when a non-citizen applicant was Permanently Residing [in
the United States] Under Color of Law (PRUCOL). The INS would indicate if this class
or category of non-citizen applicants were actively being pursued for expulsion at that
time. The PRWORA replaced the PRUCOL doctrine, and Immigration Status Verifiers
(ISVs) were instructed to no longer provide PRUCOL status determinations to benefit
issuing agencies and institutions. However, the Noncitizen Benefit Clarification and
Other Technical Amendments Act of 1998 amended PRWORA and requires INS to
provide PRUCOL information to the Social Security Administration’s Supplemental
Security Income Program (SSA/SSI). Currently, SSA/SSI is the only program receiving
PRUCOL determinations from INS.

Any additional ISV comments will be included at block 18.
The ISV will stamp and initial the front of the Document Verification Request in
the block labeled “stamp.”
The following is an explanation of the INS information a benefit issuing agency or
institution can obtain from the INS on the Document Verification Request
Supplement:
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Appendix 2

1. Immigration status. The INS will provide the non-citizen applicant’s current
immigration status by conducting a thorough search of INS automated
databases and paper files.
2. Date alien entered the United States. The INS will provide the original date
the non-citizen applicant entered the United States. (This date is not always
the same as what is provided through ASVI, when a non-citizen adjusts his or
her immigration status. In most cases, the date of entry changes in ASVI to
reflect the date the non-citizen obtained his or her Lawful Permanent
Resident status.)
3. Date status was granted. The INS will provide the date the non-citizen
obtained his or her current immigration status as noted in paragraph 1 above.
4. Date status expires. The INS will provide the date the non-citizen’s
immigration status expires. If the non-citizen’s immigration status is indefinite,
INS will provide this information in the response.
5. Citizen status. The INS will confirm whether a prior non-citizen naturalized
and is a United States citizen.
6. Special Benefit Provision for Certain Victims of Abuse. The INS will
confirm whether or not a non-citizen obtained his or her Lawful Permanent (or
Conditional) Resident status because he or she was a battered alien or a
parent of a battered child(ren) or a victim of domestic violence.
7. Affidavit of Support. The INS will confirm whether or not the non-citizen
was sponsored on Form I-864, Affidavit of Support, and if so, INS will provide
sponsorship information.
The ISV will initial and stamp the back of the form in the block labeled “Stamp.”
When the Document Verification Request and Supplement are returned, the benefit
issuing agency or institution must refer to its own eligibility requirements to determine if
the applicant qualifies for a benefit. The benefit provider makes the actual decision on
award or denial of a benefit and is responsible for the establishment of a fair hearing
process.
5-11

Delayed Replies

The Document Verification Request has been designed to allow rapid response to the
submitting agency from INS. Mandated benefit issuing agencies or institutions should
allow ten working days for processing. Other benefit issuing agencies and institutions
should wait until the expiration of the timeframe specified in the MOU for all other benefit
issuing agencies and institutions before contacting the INS Office to request information
about verification. When it becomes necessary to contact the INS Office regarding the
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status of a request, the benefit issuing agency or institution should be prepared to
furnish the non-citizen’s name, A-Number or Admission Number, and the date the
original Document Verification Request was mailed to INS.
5-12

INS Record Keeping

The INS retains records on the secondary verification process to comply with the Privacy
Act.
If any documentation submitted to an ISV indicates criminal misuse of government
documents, it may be duplicated and forwarded to the Investigations Branch of INS or to
other law enforcement agencies for initiation of an investigation or prosecution action, as
may be appropriate. The benefit issuing agency or institution should follow its own
guidelines for investigation and prosecuting cases of fraudulent documentation.

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Appendix 2

Glossary
Personnel at benefit issuing agencies and institutions will encounter unfamiliar terms in
processing applications from non-citizens.
The definitions in this glossary are
informational in nature and should not be used for any other purpose. They do not
represent any formal stance or policy of the Immigration and Naturalization Service
(INS). Official definitions have been shortened or edited whenever necessary to
facilitate use by benefit issuing agencies and institutions.
Table 4
Admission Number

An 11-digit number that is found on the
Arrival-Departure Record (Form I-94) and
should not be confused with the Alien
Registration Number (A-Number)/Alien ID
number.

Alien (Non-citizen)

Any person who is not a citizen or national
of the United States.

Alien File (A-File)

The history file containing data and
documentation pertaining to an individual
alien. An A-File is created or amended
when any one of several INS actions
occurs, for example, application for
permanent resident status.

Alien Registration Number
(A-Number)/Alien ID Number

A unique 7-, 8- or 9-digit number assigned
to an alien at the time his or her A-File is
created.

Alien Status Verification Index (ASVI)

An INS database used by benefit issuing
agencies and institutions, and other entities
in verifying non-citizen immigration status
established in accordance with the
Immigration Reform and Control Act of 1986
(IRCA).

Asylee

A non-citizen already in the United States or
at a port of entry who is granted asylum in
the United States. Asylum may be granted
to those persons who are unable or
unwilling to return to their countries of
nationality, or to seek the protection of those
countries, because of persecution or a wellfounded fear of persecution. This status is
covered by Section 208 of the Immigration
and Nationality Act (INA).
(Also see
definition for refugee, which explains the
difference between asylum and refugee in
the United States.)

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Certificate of Citizenship

An identity
citizenship.

document

proving

U.S.

Certificate of Naturalization

An identity
citizenship.

document

proving

U.S.

Change of Non–Immigrant Status

The action of changing a non–immigrant’s
classification, e.g., from visitor to student.

Citizen

A person born in a country or who has
become a naturalized citizen of that country.

Conditional Entrant

A refugee. (Refer to the definition for
refugee conditional entrant, which more fully
explains this status.)

Conditional Resident Alien

A non-citizen granted “conditional” resident
status based on marriage to a U.S. citizen
or national, or a permanent resident alien,
for whom conditional status is removed after
2 years if INS rules favorably on a petition
by the alien for retention of lawful
permanent residence. (The non-citizen’s
children can also be granted this status.)

Document Verification Request (Form
G-845)

A form used by benefit issuing agencies and
institutions, and licensing issuing bureaus to
request secondary verification of a noncitizen’s immigration status from INS.

Documented Non-citizen (Alien)

A non-citizen in the United States who is in
possession of valid INS documents.

File Control Office (FCO)

An INS office where A-files are maintained.

Green Card

A slang term describing the Alien
Registration Receipt Card. Many versions
of these forms are not green in color.

Illegal Alien

A foreign national who (a) entered the U.S.
without inspection or with fraudulent
documentation or (b) who, after entering
legally as a non–immigrant, violated status
and remained in the U.S. without
authorization.

Immigrant

A non-citizen who has been lawfully granted
the privilege of residing permanently in the
United States.

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Immigrant Visa

Appendix 2

A document, issued by a U.S. consulate or
embassy abroad, which authorizes a noncitizen to apply for admission as an
immigrant to the United States.

Immigration and Nationality Act of 1952 Legislation that defined most immigration
statutes now in use and formed the basis for
(INA)
U.S. immigration law and policies.
Immigration Reform and Control Act of
1986 (IRCA)

Legislation passed to
deter
illegal
immigration to the United States, using
employer sanctions and status verification,
and to allow legalization of specific groups
of non-citizens.

Immigration Status

The legal status conferred on a non-citizen
by immigration law.

Immigration Status Verifier (ISV)

An INS employee who performs immigration
status verification duties at local INS field
offices.

Lawful Permanent Resident

A non-citizen who has been lawfully granted
the privilege of residing permanently in the
United States.

Nationality

The state or country to which a person owes
legal allegiance. Note that the country of
birth does not necessarily correspond to the
nationality.

Naturalization

The conferring of nationality of a state or
country upon a person who has been born
under allegiance to another nation.

Non–Immigrant

A non-citizen who seeks temporary entry to
the United States for a specific purpose.
This category includes foreign government
officials, visitors for business and pleasure,
and students. Some non–immigrants have
specialized employment privileges, for
example, foreign nationals who are
employees of the U.S. office of a foreignowned company.

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Parolee

A non-citizen who appears to be
inadmissible to the inspecting officer, but
who is allowed to enter the United States
under emergency conditions or when the
non-citizen’s entry is determined to be in the
public interest.
Although parolees are
required to leave when the conditions
supporting their parole cease to exist, they
may sometimes adjust immigration status.
Parolee status is covered by Section 212 of
the INA.

Passport

Any travel document issued by competent
authority showing the bearer’s origin,
identity, and nationality, if any, which is valid
for the entry of the bearer into a foreign
country.

Permanent Resident Alien

A non-citizen who has been lawfully granted
the privilege of residing permanently in the
United States

Primary Verification

An automated query to validate a noncitizen’s immigration status using the INS
Alien Status Verification Index (ASVI)
database.

PRUCOL

A person permanently residing in the United
States under the color of law. This is not a
status defined by the INA.

Refugee

Any person who is outside their country of
nationality and who is unable or unwilling to
return to that country because of
persecution or a well-founded fear of
persecution. Unlike asylees, refugees apply
for and receive this status prior to entry into
the United States. This status is covered by
Section 207 of the INA.

Secondary Verification

A request to validate a non-citizen’s
immigration status, after or in lieu of
automated immigration status verification,
using Form G-845. Verification is performed
by an ISV using various automated or
manual sources.

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Appendix 2

Systematic Alien Verification for
Entitlements (SAVE)

An intergovernmental information-sharing
program that is available to benefit issuing
agencies and institution’s that need to
determine a non-citizen’s immigration
status.

Undocumented Non-citizen (Alien)

A non-citizen in the United States without
proper immigration documentation. He or
she is in violation of U.S. immigration law.

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Hispanic Names
The following instructions will assist user agencies in interpreting and recording Spanish
language names correctly. Although INS files reflect some discrepancies, these
guidelines were used in recording most Hispanic names. Note that the instructions do
not apply to names from other Latin-base languages, i.e., Portuguese, French, Italian, or
Romanian.

First Names
Many Spanish first names consist of more than one word, for example, Maria de los
Angeles, Maria de la Luz, and Maria del Carmen. When written with a prepositional
phrase, as in the examples above, the name should be treated as one first name. If the
name is not recorded with a prepositional phrase, for example, Maria Luz or Maria
Carmen, it should be considered first and middle names.
In recording Spanish names, nicknames should not be used. Many Spanish first names
have equivalent nicknames, which are commonly used as first names, for example,
Pancho for Francisco or Pepe for Jose.

Surnames
Hispanic persons customarily use the surnames of both parents. This double surname
is derived from the first surname of the father and the first surname of the mother.
Neither name is considered a middle name. The surname of the father precedes that of
the mother.
The two surnames may be connected by the word “Y,” which means “and” for example,
Juan Gomez Y Conde has Juan as a first name, Gomez as the surname of the father,
and Conde as the surname of the mother. Some persons may hyphenate the two
surnames, for example, Juan Gomez-Conde. For recording purposes, all double last
names are entered with the father's surname followed by the mother’s surname. Juan
Gomez Y Conde would be entered as Juan Gomez Conde.
The preposition “de” with the articles “el,” “la,” “los,” or “las” will appear in a number of
surnames. For example, the surname may be shown as de la Torre, de Alba, del Arco,
or de la Cruz. Prepositions of this nature that precede the first surname are ignored in
indexing. For example, the name of Jose de la Torre Munoz is recorded as Torre
Munoz, Jose de la.

Married Names for Women
When a woman marries, she commonly drops the surname of her mother and adds the
first surname of her husband, preceded by the preposition “de”. This indicates she is the
“wife of" that man. Maria Gomez Garcia, when married to Juan Martinez Ramirez, would
become Maria Gomez de Martinez and will be entered as Gomez de Martinez, Maria.
In the event of the husband’s death, the woman retains the same name and adds the
phase “vda. de,” meaning “widow of." For example, after her husband’s death the
woman’s name would be Maria Gomez vda. de Martinez and should be entered as
Gomez vda. de Martinez, Maria.

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Appendix 2

Note that the woman’s first surname never changes, according to traditional Hispanic
usage. After admission to the United States, however, some women have adopted the
American custom of using the husband’s surname as their own. Maria Gomez de
Martinez may begin to give her name as Martinez, Maria Gomez.

INS Office Locations
State or
Territory

Counties

INS Office

Alabama

Atlanta, GA

Alaska

Anchorage,
AK

Arizona

Phoenix,
AZ

Arkansas

Memphis,
TN

California

Inyo, Kern, Los Angeles, Orange, Riverside, San
Bernardino, San Luis Obispo, Santa Barbara, and Ventura

Los
Angeles,
CA

California

Imperial and San Diego

San Diego,
CA

California

Alameda, Alpine, Amador, Butte, Calaveras, Colusa,
Contra Costa, Del Norte, El Dorado, Fresno, Glenn,
Humboldt, Kings, Lake, Lassen, Madera, Marin, Mariposa,
Mendocino, Merced, Modoc, Mono, Monterey, Napa,
Nevada, Placer, Plumas, Sacramento, San Benito, San
Francisco, San Joaquin, San Mateo, Santa Clara, Santa
Cruz, Shasta, Sierra, Siskiyou, Solono, Sonoma,
Stanislaus, Sutter, Tehama, Trinity, Tulare, Tuolumne,
Yolo, and Yuba

San
Francisco,
CA

Colorado

Denver, CO

Connecticut

Hartford,
CT

Delaware

Philadelphi
a, PA

District of
Columbia
Florida

Washington
, DC
Miami, FL

Georgia

Atlanta, GA

Guam

Agana, GU

Hawaii

Honolulu,
HI

Idaho

Helena, MT

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4350.3 REV-1

Illinois

Chicago, IL

Indiana

Indianapolis
, IN

Iowa

Omaha, NE

Kansas

Kansas
City, MO

Kentucky

Memphis,
TN

Louisiana

New
Orleans, LA

Maine

Portland,
ME

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4350.3 REV-1

State or
Territory

Appendix 2

Counties

Maryland

Baltimore,
MD

Massachusetts

Boston, MA

Michigan

Detroit, MI

Minnesota

St. Paul,
MN

Mississippi

Alcorn, Attala, Benton, Bolivar, Calhoun, Carroll,
Memphis,
Chickasaw, Choctaw, Clay, Coahoma, DeSoto, Grenada,
TN
Humphreys, Itawamba, Lafayette, Lee, Leflore, Lowndes,
Marshall, Monroe, Montgomery, Oktibbeha, Panola,
Pontotoc, Prentiss, Quitman, Sunflower, Tallahatchie, Tate,
Tippah, Tishomingo, Tunica, Union, Washington, Webster,
Winston, and Yalobusha

Mississippi

Adams, Amite, Claiborne, Clarke, Copiah, Covington,
Forrest, Franklin, George, Greene, Hancock, Harrison,
Hinds, Holmes, Issaquena, Jackson, Jasper, Jefferson,
Jefferson Davis, Jones, Kemper, Lamar, Lauderdale,
Lawrence, Leake, Lincoln, Madison, Marion, Neshoba,
Newton, Noxubee, Pearl River, Perry, Pike, Rankin, Scott,
Sharkey, Simpson, Smith, Stone, Walthall, Warren,
Wayne, Wilkinson, and Yazoo

Missouri

Kansas
Andrew, Atchison, Barry, Barton, Bates, Benton, Boone,
Buchanan, Caldwell, Callaway, Camden, Carroll, Cass,
City, MO
Cedar Christian, Clay, Clinton, Cole, Cooper, Dade, Dallas,
Daviess, De Kalb, Douglas, Gentry, Greene, Grundy,
Harrison, Henry, Hickory, Holt, Howard, Howell, Jackson,
Jasper, Johnson, Laclede, Lafayette, Lawrence,
Livingston, McDonald, Mercer, Miller, Moniteau, Morgan,
Newton, Nodaway, Oregon, Osage, Ozark, Pettis, Platte,
Polk, Pulaski, Putnam, Ray, St. Clair, Saline, Stone,
Sullivan, Taney, Texas, Vernon, Webster, Worth, and
Wright

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New
Orleans, LA

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Appendix 2: Systematic Alien Verification for
Entitlements (SAVE) Program Instructions
Manual for the Department Housing and
Urban Development

Appendix 2

Missouri

4350.3 REV-1

Adair, Audrain, Bollinger, Butler, Cape Girardeau, Carter,
Chariton, Clark, Crawford, Dent, Dunklin, Franklin,
Gasconade, Iron, Jefferson, Knox, Lewis, Lincoln, Linn,
Macon, Madison, Maries, Marion, Mississippi, Monroe,
Montgomery, New Madrid, Pemiscot, Perry, Phelps, Pike,
Ralls, Randolph, Reynolds, Ripley, St. Charles, St.
Francois, St. Louis, Ste. Genevieve, Schuyler, Scotland,
Scott, Shannon, Shelby, Stoddard, Warren, Washington,
and Wayne

St. Louis,
MO

Montana

Helena, MT

Nebraska

Omaha, NE

Nevada

Clark, Esmeralda, Lincoln, and Nye

Las Vegas,
NV

Nevada

Churchill, Douglas, Elko, Eureka, Humboldt, Lander, Lyon,
Mineral, Pershing, Storey, Washoe, and White Pine

Reno, NV

New
Hampshire

Boston, MA

New Jersey

Newark, NJ

New Mexico

El Paso, TX

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Entitlements (SAVE) Program Instructions
Manual for the Department of Housing and
Urban Development

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4350.3 REV-1

State or
Territory
New York

Appendix 2

Counties

INS Office

Albany, Broome, Chenango, Columbia, Delaware, Fulton,
Greene, Hamilton, Herkimer, Madison, Montgomery,
Oneida, Otsego, Rensselaer, Saratoga, Schenectady,
Schoharie, Tioga, Warren, and Washington

Albany, NY

New York

Buffalo, NY
Allegany, Cattaraugus, Cayuga, Chautauqua, Chemung,
Clinton, Cortland, Erie, Essex, Franklin, Genessee,
Jefferson, Lewis, Livingston, Monroe, Niagara, Onondaga,
Ontario, Orleans, Oswego, St. Lawrence, Schuyler,
Seneca, Steuben, Tompkins, Wayne, Wyoming, and Yates

New York

Bronx, Dutchess, Kings, Nassau, New York, Orange,
Putnam, Queens, Richmond, Rockland, Suffolk, Sullivan,
Ulster, and Westchester

New York,
NY

North
Carolina

Charlotte,
NC

North Dakota

St. Paul,
MN

Ohio

Cleveland,
OH

Oklahoma

Dallas, TX

Oregon

Portland,
OR

Pennsylvania Adams, Berks, Bradford, Bucks, Cameron, Carbon, Centre, Philadelphi
Chester, Clinton, Columbia, Cumberland, Dauphin,
a, PA
Delaware, Franklin, Fulton, Huntingdon, Juniata,
Lackawanna, Lancaster, Lebanon, Lehigh, Luzerne,
Lycoming, Mifflin, Monroe, Montgomery, Montour,
Northampton, Northumberland, Perry, Philadelphia, Pike,
Potter, Schuylkill, Snyder, Sullivan, Susquehanna, Tioga,
Union, Wayne, Wyoming, and York
Pennsylvania Allegheny, Armstrong, Beaver, Bedford, Blair, Butler,
Cambria, Clarion, Clearfield, Crawford, Elk, Erie, Fayette,
Forest, Greene, Indiana, Jefferson, Lawrence, McKean,
Mercer, Somerset, Venango, Warren, Washington, and
Westmoreland

Pittsburgh,
PA

Puerto Rico

San Juan,
PR

Rhode Island

Providence,
RI

South
Carolina

Charlotte,
NC

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Urban Development

Appendix 2

4350.3 REV-1

South Dakota

St. Paul,
MN

Tennessee

Memphis,
TN

HUD Occupancy Handbook
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Entitlements (SAVE) Program Instructions
Manual for the Department of Housing and
Urban Development

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4350.3 REV-1

State or
Territory
Texas

Appendix 2

Counties

INS Office

Dallas TX
Anderson, Andrews, Archer, Armstrong, Bailey, Baylor,
Borden, Bosque, Bowie, Briscoe, Callahan, Camp, Carson,
Cass, Castro, Cherokee, Childtess, Clay, Cochran, Coilin,
Coilingsworth, Comanche, Cooke, Cottie, Crosby, Dallam,
Dallas, Dawson, Deaf Smith, Delta, Denton, Dickens,
Donley, Eastland, Ellis, Erath, Fannin, Fisher, Floyd,
Foard, Franklin, Freestone, Gaines, Garza, Gray, Grayson,
Gregg, Hale, Hall, Hamilton, Hansford, Hardeman,
Harrison, Hartley, Haskell, Hemphill, Henderson, Hill,
Hockley, Hood, Hopkins, Houston, Howard, Hunt,
Hutchinson, Jack, Johnson, Jones, Kaufman, Kent, King,
Knox, Lamar, Lamb, Leon, Limestone, Lipscomb, Lubbock,
Lynn, Marion, Martin, Mitchell, Montague, Moore, Morris,
Motley, Navarro, Nolan, Oehiltree, Oldham, Palo Pinto,
Panola, Parker, Parmer, Potter, Rains, Randall, Red River,
Roberts, Rockwall, Rusk, Scurry, Shackelford, Sherman,
Smith, Somervell, Stephens, Stonewall, Swisher, Tarrant,
Taylor, Terry, Throckmorton, Titus, Upshur, Van Zandt,
Wheeler, Wichita, Wilbarger, Wise, Wood, Yoakum, and
Young

Texas

Brewster, Crane, Culberson, Eetor, El Paso, Hudspeth,
Jeff Davis, Loving, Midland, Pecos, Presidio, Reeves,
Terrell, Upton, Ward, and Winkler

El Paso, TX

Texas

Brooks, Cameron, Hidalgo, Kenedy, Kleberg, Starr, and
Willacy

Harlingen,
TX

Texas

Angelina, Austin, Brazoria, Chambers, Colorado, Fort
Bend, Galveston, Grimes, Hardin, Harris, Jasper,
Jefferson, Liberty, Madison, Matagorda, Montgomery,
Nacogdoches, Newton, Orange, Polk, Sabine, San
Augustine, San Jacinto, Shelby, Trinity, Tyler, Walker,
Waller, Washington, and Wharton

Houston,
TX

Texas

San
Aransas, Atascosa, Bandera, Bastrop, Bee, Bell, Baxar,
Blanco, Brazos, Brown, Burieson, Burner, Caldwell,
Antonio, TX
Calhoun, Coke, Coleman, Comal, Concho, Coryell,
Crockett, DeWitt, Dimmit, Duval, Edwards, Fails, Fayette,
Frio, Gillespie, Glasscock, Goliad, Gonzales, Guadalupe,
Harp, Hayes, Irion, Jackson, Jim Hogg, Jim Wells, Karnes,
Kendall, Kerr, Kimble, Kinney, Lampasas, La Saile,
Lavaca, Lee, Live Oak, Llano, McCulloch, McLennan,
McMullen, Mason, Maverick, Medina, Menard, Milam, Mills,
Nueces, Reagan, Real, Refugio, Robertson, Runnels, San
Patricio, San Saba, Schleicher, Sterling, Sutton, Tom
Green, Travis, Uvalde, Val Verde, Victoria, Webb,
Williamson, Wilson, Zapata, and Zavala

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Utah

Denver, CO

Vermont

St. Albans,
VT

Virginia

State or
Territory
Virginia

Accomack, Amelia, Brunswick, Caroline, Charles City,
Chesterfield, Colonial Heights, Dinwiddie, Essex,
Fredericksburg, Gloucester, Goochland, Greensville,
Hanover, Henrico, Isle of Wight, James City, King and
Queen, King William, Lancaster, Louisa, Lunenburg,
Mathews, Mecklenburg, Middlesex, New Kent,
Northampton, Northumberland, Nottoway, Powhatan,
Prince Edward, Prince George, Richmond, Southhampton,
Spotsylvania, Surry, Sussex, Westmoreland, and York
Counties

Norfolk, VA

Albemarle, Alleghany, Amherst, Appomattox, Arlington,
Augusta, Bath, Bedford, Bland, Botetourt, Buchanan,
Buckingham, Campbell, Carroll, Charlotte, Clarke, Craig,
Culpepper, Cumberland, Dickenson, Fairfax, Fauquier,
Floyd, Fluvanna, Franklin, Frederick, Giles, Grayson,
Greene, Halifax, Henry, Highland, King George, Lee,
Loudoun, Madison, Montgomery, Nelson, Orange, Page,
Patrick, Pittsylvania, Prince William, Pulaski,
Rappahannock, Roanoke, Rockbridge, Rockingham,
Russell, Scott, Shenandoah, Smyth, Stafford, Tazewell,
Warren, Warwick, Washington, Wise, and Wythe

Washington
, DC

INS Office

Virgin Islands

St. Thomas,
VI

Washington
Washington,
DC
West Virginia

Seattle, WA
Washington
, DC
Philadelphi
a, PA

Wisconsin

Milwaukee,
WI

Wyoming

Denver, CO

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Entitlements (SAVE) Program Instructions
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Urban Development

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INS Office Addresses
Alaska, Anchorage (ANC)

620 East 10th Avenue
Suite 102
Anchorage, AK 99501-3708
Attention: Immigration Status Verifier
Telephone: (907) 271-3418
Facsimile: (907) 271-3112

Arizona, Phoenix (PHO)

400 N. 5th Street, 11th Floor
Phoenix, AZ 85004
Attention: Immigration Status Verifier
Telephone: (602) 514-7711 or 7389
Facsimile: (602) 379-7791

California, Los Angeles (LOS)

300 N. Los Angeles Street
Los Angeles, CA 90012
Attention: Immigration Status Verifier
Telephone: (213) 894-6808 or 6573 or 6474
Facsimile: (213) 894-6660

California, San Diego (SND)

880 Front Street
San Diego, CA 92101
Attention: Immigration Status Verifier
Telephone: (619) 557-6727
Facsimile: (619) 557-6565

California, San Francisco (SFR)

Appraisers Building
630 Sansome Street
Room 312
San Francisco, CA 94111-2280
Attention: Immigration Status Verifier
Telephone: (415) 844-5121 or 5122 or 5123 or
5124
Facsimile: (415) 844-5120

Colorado, Denver (DEN)

4730 Paris Street
Denver, CO 80239
Attention: Immigration Status Verifier
Telephone: (303) 371-4415, Ext. 142
Facsimile: (303) 361-0617

Connecticut, Hartford (HAR)

450 Main Street
Ribicoff Federal Building, Room 444
Hartford, CT 06103-3060
Attention: Immigration Status Verifier
Telephone: (860) 240-3166 or 3052
Facsimile: (860) 240-3838

4350.3 REV-1

Appendix 2

Florida, Miami (MIA)

7880 Biscayne Boulevard
Miami, FL 33138
Attention: Immigration Status Verifier
Telephone: (305) 762-3317 or 3667 or 3668
Facsimile: (305) 536-5708

Georgia, Atlanta (ATL)

77 Forsyth Street, SW
Atlanta, GA 30303
Attention: Immigration Status Verifier
Telephone: (404) 331-3251
Facsimile: (404) 331-3019

Guam, Agana (AGA)

Sirena Plaza
Suite 100
108 Hernan Cortez Avenue
Hagatna, GU 96910
Attention: Immigration Status Verifier
Telephone: (671) 472-7204
Facsimile: (671) 472-7491

Hawaii, Honolulu, (HHW)

595 Ala Moana Boulevard
Honolulu, HI 96813
Attention: Immigration Status Verifier
Telephone: (808) 532-2726 or 2727
Facsimile: (808) 532-4687

Illinois, Chicago (CHI)

10 W. Jackson Boulevard, Room 222
Chicago, IL 60604
Attention: Immigration Status Verifier
Telephone: (312) 385-1806
Facsimile: (312) 385-3409

Indiana, Indianapolis (INP)

950 N. Meridan Street
Gateway Plaza, Room 400
Indianapolis, IN 46204
Attention: Immigration Status Verifier
Telephone: (317) 226-6162
Facsimile: (317) 226-5424

Louisiana, New Orleans (NOL)

Postal Service Building
Room T-8005
701 Loyola Avenue
New Orleans, LA 70113
Attention: Immigration Status Verifier
Telephone: (504) 589-6860
Facsimile: (504) 589-4451

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Urban Development

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Appendix 2

Maine, Portland (POM)

176 Gannett Drive
South Portland, ME 04106
Attention: Immigration Status Verifier
Telephone: (207) 780-3628, Ext. 217
Facsimile: (207) 780-3481

Maryland, Baltimore (BAL)

Fallon Federal Building
31 Hopkins Plaza
Baltimore, MD 21201
Attention: Immigration Status Verifier
Telephone: (410) 962-2436 or 2437
Facsimile: (410) 962-2105

Massachusetts, Boston (BOS)

JFK Federal Building
Government Center
Boston, MA 02203
Attention: Immigration Status Verifier
Telephone: (617) 565-4897 or 3046
Facsimile: (617) 565-4529

Michigan, Detroit (DET)

Federal Building
333 Mt. Elliott Street
Detroit, MI 48207
Attention: Immigration Status Verifier
Telephone: (313) 568-6058, Voice Mail 765
Facsimile: (313) 568-6004

Minnesota, St. Paul (SPM)

2901 Metro Drive
Suite 100
Bloomington, MN 55425
Attention: Immigration Status Verifier
Telephone: (612) 313-9032 (Press 3)
Facsimile: (612) 335-9034

Missouri, Kansas City (KAN)

9747 N. Conant Avenue
Kansas City, MO 64153
Attention: Immigration Status Verifier
Telephone: (816) 891-6745
Facsimile: (816) 891-7639

Missouri, St. Louis (STL)

Robert A. Young Federal Building
1222 Spruce Street
Room 1.100
St. Louis, MO 63103-2815
Attention: Immigration Status Verifier
Telephone: (314) 539-2517
Facsimile: (314) 539-2444

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Appendix 2

Montana, Helena (HEL)

2800 Skyway Drive
Helena, MT 59601
Attention: Immigration Status Verifier
Telephone: (406) 449-5428
Facsimile: (406) 449-5752

Nebraska, Omaha (OMA)

3736 S. 132nd Street
Omaha, NE 68144
Attention: Immigration Status Verifier
Telephone: (402) 697-9302 or 9305
Facsimile: (402) 697-9064

Nevada, Las Vegas (LVG)

3373 Pepper Lane
Las Vegas, NV 89120-2739
Attention: Immigration Status Verifier
Telephone: (702) 388-6626 or 6868 or 6865
Facsimile: (702) 388-6627

Nevada, Reno (REN)

1351 Corporate Boulevard
Reno, NV 89502
Attention: Immigration Status Verifier
Telephone: (775) 784-5186
Facsimile: (775) 784-5899

New Jersey, Newark (NEW)

Federal Building
970 Broad Street
Newark, NJ 07102
Attention: Immigration Status Verifier
Telephone: (973) 504-6902
Facsimile: (973) 645-2304

New York, Albany (ALB)

1086 Troy-Schenectady Road
Latham, NY 12110
Attention: Immigration Status Verifier
Telephone: (518) 220-2100, Ext. 117
Facsimile: (518) 220-2171

New York, Buffalo (BUF)

130 Delaware Avenue
Buffalo, NY 14202
Attention: Immigration Status Verifier
Telephone: (716) 551-4741, Ext. 4627 or Ext. 4275
Facsimile: (716) 551-4720

New York, New York (NYC)

26 Federal Plaza
7th Floor, Room 130
New York, NY 10278
Attention: Immigration Status Verifier
Telephone: (212) 264-5740 or 5766 or 5073 or
5872
Facsimile: (212) 264-5436

HUD Occupancy Handbook
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Entitlements (SAVE) Program Instructions
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Urban Development

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Appendix 2

North Carolina, Charlotte (CLT)

210 East Woodlawn Road
Building 6, Suite 138
Charlotte, NC 28217
Attention: Immigration Status Verifier
Telephone: (704) 672-6940
Facsimile: (704) 672-6989

Ohio, Cleveland (CLE)

1240 East 9th Street
Room 1917
Cleveland, OH 44199
Attention: Immigration Status Verifier
Telephone: (216) 522-2268 or (216) 522-2612
Facsimile: (216) 522-7039

Oregon, Portland (POO)

Federal Office Building
511 Northwest Broadway
Portland, OR 97209
Attention: Immigration Status Verifier
Telephone: (503) 326-5934 or 5944
Facsimile: (503) 326-7182

Pennsylvania, Philadelphia (PHI)

1600 Callowhill Street
Philadelphia, PA 19130
Attention: Immigration Status Verifier
Telephone: (215) 656-7186 or 7182
Facsimile: (215) 656-7200

Pennsylvania, Pittsburgh (PIT)

314 Liberty Building
1000 Liberty Avenue
Pittsburgh, PA 15222
Attention: Immigration Status Verifier
Telephone: (412) 395-4551 or 4552
Facsimile: (412) 395-6375

Puerto Rico, San Juan (SAJ)

PO Box 365068
San Juan, PR 00936
Attention: Immigration Status Verifier
Telephone: (787) 706-2357 or 2358
Facsimile: (787) 706-2303

Rhode Island, Providence (PRO)

200 Dyer Street
Providence, RI 02903
Attention: Immigration Status Verifier
Telephone: (401) 528-5563 or 5528
Facsimile: (401) 528-5549

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Appendix 2

Tennessee, Memphis (MEM)

1341 Sycamore View
Suite 100
Memphis, TN 38134
Attention: Immigration Status Verifier
Telephone: (901) 544-0256, Ext. 121 or 122
Facsimile: (901) 544-0572

Texas, Dallas (DAL)

8101 North Stemmons Freeway
Dallas, TX 75247
Attention: Immigration Status Verifier
Telephone: (214) 905-5725 or 5726
Facsimile: (214) 905-5587

Texas, El Paso (ELP)

1545 Hawkins Boulevard
El Paso, TX 79925
Attention: Immigration Status Verifier
Telephone: (915) 225-1823 or 1824 or 1818
Facsimile: (915) 225-1812

Texas, Harlingen (HLG)

2102 Teege Street
Harlingen, TX 78550
Attention: Immigration Status Verifier
Telephone: (956) 427-8691 or 8921 or 8922
Facsimile: (956) 423-7147

Texas, Houston (HOU)

126 Northpoint Drive
Houston, TX 77060
Attention: Immigration Status Verifier
Telephone: (281) 774-4685 or 4689 or 4818
Facsimile: (281) 774-5983

Texas, San Antonio (SNA)

8940 Fourwinds Drive
Suite 2020
San Antonio, TX 78239
Attention: Immigration Status Verifier
Telephone: (210) 967-7037 or 7038 or 7039
Facsimile: (210) 967-7032

Vermont, St. Albans (STA)

Federal Building
P.O. Box 328
St. Albans, VT 05478
Attention: Immigration Status Verifier
Telephone: (802) 527-3257
Facsimile: (802) 527-3262

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Entitlements (SAVE) Program Instructions
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Urban Development

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Appendix 2

Vermont Service Center (VSC)

75 Lower Welden Street
St. Albans, VT 05479-0001
Attention: Immigration Status Verifier
Telephone: (802) 527-4700, Ext. 4676
Facsimile: (802) 527-3252 or 3159

Virginia, Norfolk (NOR)

Norfolk Commerce Park
5280 Hennemam Drive
Norfolk, VA 23513
Attention: Immigration Status Verifier
Telephone: (757) 858-6183 or 6184
Facsimile: (757) 858-6273

Virgin Islands, St. Thomas,
Charlotte Amalie (CHA)

Nisky Center
Suite 1A, First Floor South
St. Thomas, VI 00802
Attention: Immigration Status Verifier
Telephone: (340) 774-1390
Facsimile: (340) 776-4981

Washington, DC (WAS)

4420 North Fairfax Drive
Arlington, VA 22203
Attention: Immigration Status Verifier
Telephone: (202) 307-1651 or 1587 or 1558
Facsimile: (202) 307-1628

Washington, Seattle (SEA)

815 Airport Way South
Seattle, WA 98134
Attention: Immigration Status Verifier
Telephone: (206) 553-1394 or 7928 or 0636 or
0649
Facsimile: (206) 553-2730

Wisconsin, Milwaukee (MIL)

Federal Building
Room 186
517 East Wisconsin Avenue
Milwaukee, WI 53202
Attention: Immigration Status Verifier
Telephone: (414) 297-3592
Facsimile: (414) 297-3152

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Appendix 2

INS Records Systems
The Central Index System (CIS) is the centralized computer-based information system that
serves INS in both the immigration services and enforcement areas. The CIS references all
Alien Files numbered A12 000 000 and above, and many with lower numbers. The CIS users
may:
•
•
•
•

Perform searches using the Alien Registration Number, Social Security number,
Naturalization Number, and other keys.
Search records by exact name, “sounds like” name, and alias name.
Reference other INS systems that contain data pertinent to each record.
Track the location and transfer of Alien Files between INS offices.

Non–Immigrant Information System
The Non–Immigrant Information System (NIIS) is a mainframe system available to all INS
offices with access to the Department of Justice (DOJ) computer. It stores arrival and departure
records for non–immigrant foreign nationals and provides automation support for tracking their
arrivals and departures.

Alien Status Verification Index
A subset of CIS and NIIS, the Alien Status Verification Index (ASVI) database contains
information on over 60 million non-citizens and is used by benefit issuing agencies and
institutions in verifying non-citizen immigration status. Chapter 3 of this manual gives additional
information on the ASVI database.

Computer-Linked Applications Information Management System
The Computer-Linked Applications Information Management System (CLAIMS) is a local area
network (LAN) and a mainframe system that records and tracks cases for immigration benefits.
It incorporates casework-oriented software systems designed to support the processing of
applications or petitions for immigration benefits. The CLAIMS database supports the
adjudication efforts of the INS and serves as a central source for document production. The
Direct Mail Program instituted by the INS allows the public to mail applications and petitions
directly to INS Service Centers and to locations where they are processed on a LAN version of
the system. These records are then migrated to the mainframe system for further processing.
The CLAIMS also includes a receipt tracking system in which an application is received and
then adjudicated. Adjudicators working CLAIMS cases are restricted from contact with the
public in order to maintain a high level of productivity. Cases that require contact with the public
are transferred from the Service Centers to the District Offices for interviews with the applicant.
External interagency interfaces include: the Social Security Administration, the Internal Revenue
Service, the Department of State, the U.S. Customs Service, and the Federal Bureau of
Investigations.

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Students/Schools System
The Students/Schools System (STSC) is an automated database that contains information on
foreign students at U.S. academic and vocational educational institutions.

Deportable Alien Control System
The Deportable Alien Control System (DACS) is an automated database that supports field
casework activities associated with aliens who are detained or placed under docket control for
deportation or exclusion. All INS field offices have access to the system.

Alien Files
The Alien Files (A-Files) are the comprehensive paper files on individuals of interest to the INS.
The A-File contains copies of all pertinent INS documents. The jacket number on a folder is
assigned as the A-Number.

INS Microfilm Files
Before automation, many INS source documents and file indices resided on microfilm for
efficiency of storage and retrieval.

Federal Records Center Index
The INS maintains index cards of A-Files that have been retired to Federal Records Centers.
The INS may retrieve these A-Files upon request. The index cards contain much of the same
data as the CIS, including the A-Number, name, date and place of birth, date and port of entry,
and alien status.

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Appendix 2

Questions and Answers
Q: What is the SAVE program?
A: The Systematic Alien Verification for Entitlements (SAVE) program is an intergovernmental
information-sharing initiative designed to aid federal, state, and local benefit providers in
determining a non-citizen’s immigration status, and thereby ensure that only entitled noncitizens receive public benefits.
Q: What is the cost of the SAVE program to the user?

A: The cost of access to the Immigration and Naturalization Service’s Alien Status
Verification Index (ASVI) varies by access method. We currently offer five different
access methods with a transaction cost that varies from $.02 to $.23 per query.
Q: What is the system’s response time?

A: The response time for a primary (automated) query of the ASVI database is 3 to 5
seconds. The manual verification process for the mandated agencies is within 10
working days and is negotiable with non-mandated agencies, usually within 20
working days.
Q: What safeguards exist in the SAVE system to prevent benefit issuing agencies and
institutions from erroneously denying a benefit based on a primary response from INS?

A: Under the standardized SAVE system, in most cases, a benefit is never denied,
delayed, reduced, or terminated based solely upon the response from primary. A
secondary verification procedure is in place as a precautionary measure.
Q: Is any further action required when a non-citizen’s status is verified in the Alien Status
Verification Index (ASVI)?
A: No further check is required if there are no material differences between the data in ASVI
and the information in the non-citizen’s immigration documentation, and if the status on the
screen does not state “Institute Secondary Verification.”
Q: What if the applicant’s Alien Registration Number, when queried in ASVI, shows information
about a different individual?
A: Users must make certain that biographical data matches the non-citizen applicant. If not,
“secondary verification” should be instituted with INS.

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Q: What does “Institute Secondary Verification” mean?
A: This is one response to primary verification that benefit issuing agencies and institutions will
receive from ASVI. When this message is received, obtain photocopies of the front and
back of the non-citizen’s immigration documentation, attach to a completed Document
Verification Request, and forward the form to the designated Immigration and
Naturalization Service File Control Office for secondary verification. Immigration
documentation presented by the applicant must be returned to the applicant.
Q: Is the applicant an “illegal non-citizen” when secondary verification is requested?
A: No. A request for secondary verification means that the present classification in the
computer database indicates something other than a legal permanent resident. In some
instances, this means that the non-citizen’s record is very new. Secondary verification is a
safeguard to prevent denial of benefits to eligible non-citizen applicants. It also should be
used whenever there is a discrepancy between information in ASVI and information
presented by the applicant.
Q: Does INS provide information to federal, state, and local government benefit issuing
agencies and institutions to assist them in understanding INS’ role in the SAVE process?

A: Yes. The SAVE program provides the users with user manuals and conducts
periodic users’ meetings to discuss INS’ role and address the users’ concerns. In
addition, SAVE program staff members are available to answer questions either in
writing or by telephone.
Q: Will INS be involved in verifying citizenship status?

A: Yes. The Illegal Immigration Reform and Immigrant Responsibility Act of 1996
(IIRIRA) requires INS to respond to inquiries by federal, state, and local government
agencies seeking to verify or determine the citizenship or immigration status of any
individual within the jurisdiction of the agency for any lawful purpose. Additionally,
IIRIRA provides that the Attorney General, in consultation with the Secretary of
Health and Human Services, will establish procedures for persons applying for
public benefits to provide proof of citizenship in a fair and non–discriminatory
manner.

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Q: Is INS’ database capable of providing the information that states and agencies will need?

A: INS’ current SAVE program can electronically verify the status of most lawful
permanent residents as well as aliens in many other categories. Copies of
documents must be sent to INS for further verification for certain groups of aliens or
when status cannot be verified immediately through the automated system. This
additional verification ensures that all available INS records systems can be
checked and that benefits are not delayed, denied, reduced, or terminated to
eligible persons. It is anticipated that the SAVE program will be able to
accommodate the anticipated workload under the welfare provisions.
Q: For what programs do states have to verify immigration status with the INS?

A: Verification is mandatory for federal public benefits. State and local benefit issuing
agencies and institutions may choose to verify immigration status with INS for
applicants for state and local public benefit programs.
Q: Can INS verify sponsorship information?

A: Yes. INS currently supplies benefit issuing agencies and institutions with
information that sponsors provided on the original affidavit of support. However,
this information is not currently automated and is provided through the secondary
verification process. The IIRIRA requires that INS make sponsorship information
available in the SAVE system.
Q: Are all non-citizens in the United States required to carry non-citizen registration
documents?
A: Section 264(e) of the Immigration and Nationality Act states in part that, “Every alien, 18
years of age and older, shall at all times carry with him and have in his personal possession
any certificate of alien registration or alien registration receipt card issued to him...” Failure
to comply with the provisions of this subsection constitutes a misdemeanor and, if found
guilty, a non-citizen can be subject to a fine, imprisonment, or both.
Q: What documents should a non-citizen have in his or her possession?
A: There are many types of non-citizen registration documents. Most non-citizens will have
one of the following items: Resident Alien Card (Form I-551), Employment Authorization
Card (Form I-688A), Employment Authorization Document (Form I-688B or (Form I-766),
Temporary Resident Card (I-688), Fee Receipt (Form I-689), Arrival-Departure Record
(Form I-94), Re-Entry Permit (Form I-327), or Refugee Travel Document (Form I-571).
Other types of non-citizen documentation include notifications on the letterhead of the
Immigration and Naturalization Service, U.S. stamps in passports, or INS computer-printed
fee receipts. If an applicant presents an unfamiliar type of documentation, follow the
secondary verification procedures outlined in this manual.
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Q: Is it legal to photocopy Immigration and Naturalization Service documents?
A: Most non-citizen registration documentation may be photocopied. However, use of the
copies for criminal purposes constitutes fraud. Any document issued by the Immigration
and Naturalization Service that cannot be copied will have a warning printed on the
document.

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Appendix 3
Acceptable Forms of Verification

Appendix 3

4350.3 REV-1

Appendix 3: Acceptable Forms of Verification
ACCEPTABLE SOURCES
a

Third Party
Factor to be Verified

b

Written

Oral

Documents Provided by
Applicant

c

• Age.

• None required.

• None required.

Birth Certificate
Baptismal Certificate
Military Discharge papers
Valid passport
Census document showing
age
• Naturalization certificate
• Social Security
Administration Benefits
printout

• Alimony or child support.

• Copy of separation or
divorce agreement
provided by ex-spouse
or court indicating type
of support, amount, and
payment schedule.
• Written statement
provided by ex-spouse
or income source
indicating all of above.
• If applicable, written
statement from
court/attorney that
payments are not being
received and
anticipated date of
resumption of
payments.

• Telephone or in-person
contact with ex-spouse or
income source
documented in file by the
owner.

• Copy of most recent
check, recording date,
amount, and check
number.
• Recent original letters from
the court.

Self-Declaration

Verification Tips

•
•
•
•
•

• Notarized statement or
affidavit signed by applicant
indicating amount received.
• If applicable, notarized
statement or affidavit from
applicant indicating that
payments are not being
received and describing
efforts to collect amounts
due.

• Amounts awarded but not
received can be excluded from
annual income only when
applicants have made
reasonable efforts to collect
amounts due, including filing with
courts or agencies responsible
for enforcing payments.

a

NOTE: Requests for verification from third parties must be accompanied by a Consent to Release form.
NOTE: If the original document is witnessed but is a document that should not be copied, the owner should record the type of document, any control or serial numbers, and the
issuer. The owner should also initial and date this notation in the file.
c
NOTE: For all oral verification, file documentation must include facts, time and date of contact, and name and title of third party.
b

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Appendix 3

Appendix 3: Acceptable Forms of Verification
ACCEPTABLE SOURCES
a

Third Party
Factor to be Verified
• Assets disposed of for less
than fair market value.

b

Written

• None required.

Oral

c

• None required.

Documents Provided by
Applicant
• None required.

Self-Declaration
• Certification signed by
applicant that no member of
family has disposed of
assets for less than fair
market value during
preceding two years.

Verification Tips
• Only count assets disposed of
within a two-year period prior to
examination or re-examination.

• If applicable, certification
signed by the owner of the
asset disposed of that
shows:
- Type of assets disposed of;
- Date disposed of;
- Amount received; and
- Market value of asset at
the time of disposition.

a

NOTE: Requests for verification from third parties must be accompanied by a Consent to Release form.
NOTE: If the original document is witnessed but is a document that should not be copied, the owner should record the type of document, any control or serial numbers, and the
issuer. The owner should also initial and date this notation in the file.
c
NOTE: For all oral verification, file documentation must include facts, time and date of contact, and name and title of third party.
b

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4350.3 REV-1

Appendix 3: Acceptable Forms of Verification
ACCEPTABLE SOURCES
a

Third Party
Factor to be Verified
• Auxiliary apparatus.

b

Written

• Written verification from
source of costs and
purpose of apparatus.

Oral

c

Documents Provided by
Applicant

• Telephone or in-person
contact with these
sources documented in
file by the owner.

• Copies of receipts or
evidence of periodic
payments for apparatus.

• Telephone or in-person
contact with source
documented in file by the
owner.

• Copies of receipts or
cancelled checks
indicating payment
amount and frequency.

Self-Declaration

Verification Tips
• The owner must determine if
expense is to be considered
medical or disability assistance.

• Written certification from
doctor or rehabilitation
agency that use of
apparatus is necessary
to employment of any
family member.
• In case where the
disabled person is
employed, statement
from employer that
apparatus is necessary
for employment.
• Care attendant for
disabled family members.

• Written verification from
attendant stating
amount received,
frequency of payments,
hours of care.

• Notarized statement or
signed affidavit attesting to
amounts paid.

• The owner must determine if this
expense is to be considered
medical or disability assistance.

• Written certification from
doctor or rehabilitation
agency that care is
necessary to
employment of family
member.

a

NOTE: Requests for verification from third parties must be accompanied by a Consent to Release form.
NOTE: If the original document is witnessed but is a document that should not be copied, the owner should record the type of document, any control or serial numbers, and the
issuer. The owner should also initial and date this notation in the file.
c
NOTE: For all oral verification, file documentation must include facts, time and date of contact, and name and title of third party.
b

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Appendix 3

Appendix 3: Acceptable Forms of Verification
ACCEPTABLE SOURCES
a

Third Party
b

Factor to be Verified

Written

• Child care expenses
(including verification that
a family member who has
been relieved of child care
is working, attending
school, or looking for
employment).

• Written verification from
person who provides
care indicating amount
of payment, hours of
care, names of children,
frequency of payment,
and whether or not care
is necessary to
employment or
education.
• Verification of
employment as required
under Employment
Income.

Oral

c

• Telephone or in-person
contact with these
sources (child care
provider, employer,
school) documented in
file by the owner.

Documents Provided by
Applicant
• Copies of receipts or
cancelled checks
indicating payments.

Self-Declaration

Verification Tips

• For verification of “looking for
work,” details of job search
effort as required by owner’s
written policy.

• Allowance provided only for care
of children 12 and younger.

• For school attendance,
school records, such as
paid fee statements that
show that the time and
duration of school
attendance reasonably
corresponds to the period
of child care.

• When same care provider takes
care of children and disabled
person, the owner must prorate
expenses accordingly.
• Owners should keep in mind that
costs may be higher in summer
months and during holiday
periods.
• The owner must determine which
family member has been
enabled to work.

• Verification of student
status (full or part-time)
as required under FullTime Student Status.

• Care for employment and
education must be prorated to
compare to earnings.
• Costs must be “reasonable.”

• Citizenship

• Citizens must sign
declaration certifying U.S.
Citizenship.

• Owners may require
applicants/residents to provide
verification of citizenship.

a

NOTE: Requests for verification from third parties must be accompanied by a Consent to Release form.
NOTE: If the original document is witnessed but is a document that should not be copied, the owner should record the type of document, any control or serial numbers, and the
issuer. The owner should also initial and date this notation in the file.
c
NOTE: For all oral verification, file documentation must include facts, time and date of contact, and name and title of third party.
b

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4350.3 REV-1

Appendix 3: Acceptable Forms of Verification
ACCEPTABLE SOURCES
a

Third Party
Factor to be Verified
• Current net family assets.

b

c

Written

Oral

• Verification forms,
letters or documents
received from financial
institutions, stock
brokers, real estate
agents, employers
indicating the current
value of the assets and
penalties or reasonable
costs to be incurred in
order to convert
nonliquid assets into
cash.

• Telephone or in-person
contact with appropriate
source, documented in
file by the owner.

Documents Provided by
Applicant
• Passbooks, checking, or
savings account
statements, certificates of
deposit, property
appraisals, stock or bond
documents, or other
financial statements
completed by financial
institution.
• Copies of real estate tax
statements, if tax authority
uses approximate market
value.
• Quotes from attorneys,
stockbrokers, bankers,
and real estate agents that
verify penalties and
reasonable costs incurred
to convert asset to cash.

Self-Declaration

Verification Tips

• Notarized statement or
signed affidavit stating cash
value of assets or verifying
cash held at applicant’s
home or in safe deposit box.

• Use current balance in savings
accounts and average monthly
balance in checking accounts for
last 6 months.
• Use cash value of all assets (the
net amount the applicant would
receive if the asset were
converted to cash).
• NOTE: This information can
usually be obtained
simultaneously when verifying
income from assets and
employment (e.g., value of
pension).

• Copies of real estate
closing documents that
indicate distribution of
sales proceeds and
settlement costs.

a

NOTE: Requests for verification from third parties must be accompanied by a Consent to Release form.
NOTE: If the original document is witnessed but is a document that should not be copied, the owner should record the type of document, any control or serial numbers, and the
issuer. The owner should also initial and date this notation in the file.
c
NOTE: For all oral verification, file documentation must include facts, time and date of contact, and name and title of third party.
b

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Appendix 3

Appendix 3: Acceptable Forms of Verification
ACCEPTABLE SOURCES
a

Third Party
Factor to be Verified
• Disability status.

b

Written

• Verification from
medical professional
stating that individual
qualifies under the
definition of disability.

Oral

c

Documents Provided by
Applicant

• Telephone or in-person
contact with medical
professional verifying
qualification under the
federal disability
definition and
documentation in the file
of the conversation.

Self-Declaration
• Not appropriate.

Verification Tips
• If a person receives Social
Security Disability solely due to a
drug or alcohol problem, the
person is not considered
disabled under housing law. A
person that does not receive
Social Security Disability may
still qualify under the definition of
a person with disabilities.
• Owners must not seek to verify
information about a person’s
specific disability other than
obtaining a professional’s
opinion of qualification under the
definition of a person with
disabilities.

a

NOTE: Requests for verification from third parties must be accompanied by a Consent to Release form.
NOTE: If the original document is witnessed but is a document that should not be copied, the owner should record the type of document, any control or serial numbers, and the
issuer. The owner should also initial and date this notation in the file.
c
NOTE: For all oral verification, file documentation must include facts, time and date of contact, and name and title of third party.
b

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Appendix 3: Acceptable Forms of Verification
ACCEPTABLE SOURCES
a

Third Party
Factor to be Verified
• Dividend income and
savings account interest
income.

b

Written

• Verification form
completed by bank.

Oral

c

• Telephone or in-person
contact with appropriate
party, documented in file
by the owner.

Documents Provided by
Applicant
• Copies of current
statements, bank
passbooks, certificates of
deposit, if they show
required information (i.e.,
current rate of interest).

Self-Declaration
• Not appropriate.

Verification Tips
• The owner must obtain enough
information to accurately project
income over next 12 months.
• Verify interest rate as well as
asset value.

• Copies of Form 1099 from
the financial institution,
and verification of
projected income for the
next 12 months.
• Broker’s quarterly
statements showing value
of stocks/bonds and
earnings credited to the
applicant.

a

NOTE: Requests for verification from third parties must be accompanied by a Consent to Release form.
NOTE: If the original document is witnessed but is a document that should not be copied, the owner should record the type of document, any control or serial numbers, and the
issuer. The owner should also initial and date this notation in the file.
c
NOTE: For all oral verification, file documentation must include facts, time and date of contact, and name and title of third party.
b

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Appendix 3

Appendix 3: Acceptable Forms of Verification
ACCEPTABLE SOURCES
a

Third Party
Factor to be Verified
• Employment Income
including tips, gratuities,
overtime.

b

c

Written

Oral

• Verification form
completed by employer.

• Telephone or in-person
contact with employer,
specifying amount to be
paid per pay period and
length of pay period.
Document in file by the
owner.

Documents Provided by
Applicant
• W-2 Forms, if applicant
has had same employer
for at least two years and
increases can be
accurately projected.
• Paycheck stubs or earning
statements.

Self-Declaration

Verification Tips

• Notarized statements or
affidavits signed by applicant
that describe amount and
source of income.

• Always verify: frequency of gross
pay (i.e., hourly, biweekly,
monthly, bimonthly); anticipated
increases in pay and effective
dates; overtime.
• Require most recent 6-8
consecutive pay stubs; do not
use check without stub.
• For a fee, additional information
can be obtained from The Work
Number 800-996-7556; First
American Registry 800-9990350; and Verifax 800-969-5100.
Fees are valid project expenses.
Information does not replace
third-party verification.

a

NOTE: Requests for verification from third parties must be accompanied by a Consent to Release form.
NOTE: If the original document is witnessed but is a document that should not be copied, the owner should record the type of document, any control or serial numbers, and the
issuer. The owner should also initial and date this notation in the file.
c
NOTE: For all oral verification, file documentation must include facts, time and date of contact, and name and title of third party.
b

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Appendix 3: Acceptable Forms of Verification
ACCEPTABLE SOURCES
a

Third Party
Factor to be Verified
• Family composition.

b

Written

• None required.

Oral

c

• None required.

•
•
•
•
•
•
•
•
•
•
•
•

• Family type.
(Information verified only to
determine eligibility for
project, preferences, and
allowances.)

• Disability Status:
statement from
physician or other
reliable source, if
benefits documenting
status are not received.
See paragraph 3.25 B.1
for restrictions on this
form of verification.
• Displacement Status:
Written statement or
certificate of
displacement by the
appropriate
governmental authority.

• Telephone or in-person
contact with source
documented in file by the
owner.

Documents Provided by
Applicant
Birth certificates
Divorce actions
Drivers’ licenses
Employer records
Income tax returns
Marriage certificates
School records
Social Security
Administration records
Social service agency
records
Support payment records
Utility bills
Veterans Administration
(VA) records

• Elderly Status (when there
is reasonable doubt that
applicant is at least 62):
birth certificate, baptismal
certificate, social security
records, driver’s license,
census record, official
record of birth or other
authoritative document or
receipt of SSI old age
benefits or SS benefits.
• Disabled, blind: evidence
of receipt of SSI or
Disability benefits.

Self-Declaration

Verification Tips
• An owner may seek verification
only if the owner has clear written
policy.

• Elderly Status: Applicant’s
signature on application is
generally sufficient.

• Unless the applicant receives
income or benefits for which
elderly or disabled status is a
requirement, such status must
be verified.
• Status of disabled family
members must be verified for
entitlement to $480 dependent
deduction and disability
assistance allowance.
• Owner may not ask the
nature/extent of disability.

a

NOTE: Requests for verification from third parties must be accompanied by a Consent to Release form.
NOTE: If the original document is witnessed but is a document that should not be copied, the owner should record the type of document, any control or serial numbers, and the
issuer. The owner should also initial and date this notation in the file.
c
NOTE: For all oral verification, file documentation must include facts, time and date of contact, and name and title of third party.
b

HUD Occupancy Handbook
Appendix 3: Acceptable Forms of Verification

9

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4350.3 REV-1

Appendix 3

Appendix 3: Acceptable Forms of Verification
ACCEPTABLE SOURCES
a

Third Party
b

c

Documents Provided by
Applicant

Factor to be Verified

Written

• Full-time student status (of
family member 18 or older,
excluding head, spouse,
or foster children).

• Verification from the
Admissions or
Registrar’s Office or
dean, counselor,
advisor, etc., or from VA
Office.

• Telephone or in-person
contact with these
sources documented in
file by the owner.

• School records, such as
paid fee statements that
show a sufficient number
of credits to be considered
a full-time student by the
educational institution
attended.

• Immigration Status.

• Verification of eligible
immigration status must
be received from DHS
through the DHS SAVE
system or through
secondary verification
using DHS Form G-845.

• None.

• Applicant/resident must
provide appropriate
immigration documents to
initiate verification.

Oral

Self-Declaration

Verification Tips

• Noncitizens must sign
declaration certifying the
following:
− Eligible immigration status;
or
− Decision not to claim
eligible status.

• Owners must require noncitizens
requesting assistance to provide
verification of eligible immigration
status.

a

NOTE: Requests for verification from third parties must be accompanied by a Consent to Release form.
NOTE: If the original document is witnessed but is a document that should not be copied, the owner should record the type of document, any control or serial numbers, and the
issuer. The owner should also initial and date this notation in the file.
c
NOTE: For all oral verification, file documentation must include facts, time and date of contact, and name and title of third party.
b

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HUD Occupancy Handbook
Appendix 3: Acceptable Forms of Verification

Appendix 3

4350.3 REV-1

Appendix 3: Acceptable Forms of Verification
ACCEPTABLE SOURCES
a

Third Party
Factor to be Verified
• Income maintenance
payments, benefits,
income other than wages
(i.e., welfare, Social
Security [SS],
Supplemental Security
Income [SSI], Disability
Income, Pensions).

b

Written

Oral

c

Documents Provided by
Applicant

• Award or benefit
notification letters
prepared and signed by
authorizing agency.

• Telephone or in-person
contact with income
source, documented in
file by the owner.

• Current or recent check
stubs with date, amount,
and check number
recorded by the owner.

• TRACS or REAC may
provide verification for
social security.

• NOTE: For all oral
verification, file
documentation must
include facts, time and
date of contact, and
name and title of third
party.

• Award letters or computer
printout from court or
public agency.
• Copies of validated bank
deposit slips, with
identification by bank.
• Most recent quarterly
pension account
statement.

• Interest from sale of real
property (e.g., contract for
deed, installment sales
contract, etc.)

• Verification form
completed by an
accountant, attorney,
real estate broker, the
buyer, or a financial
institution which has
copies of the
amortization schedule
from which interest
income for the next 12
months can be
obtained.

• Telephone or in-person
contact with appropriate
party, documented in file
by the owner.

• Copy of the contract.
• Copy of the amortization
schedule, with sufficient
information for the owner
to determine the amount
of interest to be earned
during the next 12 months.
• NOTE: Copy of a check
paid by the buyer to the
applicant is not
acceptable.

Self-Declaration

Verification Tips
• Checks or automatic bank
deposit slips may not provide
gross amounts of benefits if
applicant has deductions made
for Medicare Insurance.
• Pay stubs for the most recent four
to six weeks should be obtained.
• Copying of U.S. Treasury checks
is not permitted.
• Award letters/printouts from court
or public agency may be out of
date; telephone verification of
letter/printout is recommended.
• Only the interest income is
counted; the balance of the
payment applied to the principal
is merely a liquidation of the
asset.
• The owner must get enough
information to compute the
actual interest income for the
next 12 months.

a

NOTE: Requests for verification from third parties must be accompanied by a Consent to Release form.
NOTE: If the original document is witnessed but is a document that should not be copied, the owner should record the type of document, any control or serial numbers, and the
issuer. The owner should also initial and date this notation in the file.
c
NOTE: For all oral verification, file documentation must include facts, time and date of contact, and name and title of third party.
b

HUD Occupancy Handbook
Appendix 3: Acceptable Forms of Verification

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Appendix 3

Appendix 3: Acceptable Forms of Verification
ACCEPTABLE SOURCES
a

Third Party
Factor to be Verified
• Medical expenses.

b

c

Written

Oral

• Verification by a doctor,
hospital or clinic,
dentist, pharmacist,
etc., of estimated
medical costs to be
incurred or regular
payments expected to
be made on outstanding
bills which are not
covered by insurance.

• Telephone or in-person
contact with these
sources, documented in
file by the owner.

Documents Provided by
Applicant
• Copies of cancelled
checks that verify
payments on outstanding
medical bills that will
continue for all or part of
the next 12 months.

Self-Declaration
• Notarized statement or
signed affidavit of
transportation expenses
directly related to medical
treatment, if there is no other
source of verification.

Verification Tips
• Medical expenses are not
allowable as deduction unless
applicant is an elderly or
disabled family. Status must be
verified.

• Copies of income tax
forms (Schedule A, IRS
Form 1040) that itemize
medical expenses, when
the expenses are not
expected to change over
the next 12 months.
• Receipts, cancelled
checks, pay stubs, which
indicate health insurance
premium costs, or
payments to a resident
attendant.
• Receipts or ticket stubs
that verify transportation
expenses directly related
to medical expenses.

• Need for an assistive
animal.

• Letter from medical
provider.

• If the owner’s policy is to verify
this need, owner must implement
policy consistently.

a

NOTE: Requests for verification from third parties must be accompanied by a Consent to Release form.
NOTE: If the original document is witnessed but is a document that should not be copied, the owner should record the type of document, any control or serial numbers, and the
issuer. The owner should also initial and date this notation in the file.
c
NOTE: For all oral verification, file documentation must include facts, time and date of contact, and name and title of third party.
b

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HUD Occupancy Handbook
Appendix 3: Acceptable Forms of Verification

Appendix 3

4350.3 REV-1

Appendix 3: Acceptable Forms of Verification
ACCEPTABLE SOURCES
a

Third Party
Factor to be Verified
• Net Income for a business.

b

Written

• Not applicable.

Oral

c

• Not applicable.

Documents Provided by
Applicant

Self-Declaration

Verification Tips

• Form 1040 with Schedule
C, E, or F.
• Financial Statement(s) of
the business (audited or
unaudited) including an
accountant’s calculation of
straight-line depreciation
expense if accelerated
depreciation was used on
the tax return or financial
statement.
• Any loan application listing
income derived from
business during the
preceding 12 months.
• For rental property, copies
of recent rent checks,
lease and receipts for
expenses, or IRS
Schedule E.

• Recurring contributions
and gifts.

• Notarized statement or
affidavit signed by the
person providing the
assistance giving the
purpose, dates, and
value of gifts.

• Telephone or in-person
contact with source
documented in file by the
owner.

• Not applicable.

• Notarized statement or
affidavit signed by applicant
stating purpose, dates, and
value of gifts.

• Sporadic contributions and gifts
are not counted as income.

a

NOTE: Requests for verification from third parties must be accompanied by a Consent to Release form.
NOTE: If the original document is witnessed but is a document that should not be copied, the owner should record the type of document, any control or serial numbers, and the
issuer. The owner should also initial and date this notation in the file.
c
NOTE: For all oral verification, file documentation must include facts, time and date of contact, and name and title of third party.
b

HUD Occupancy Handbook
Appendix 3: Acceptable Forms of Verification

13

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4350.3 REV-1

Appendix 3

Appendix 3: Acceptable Forms of Verification
ACCEPTABLE SOURCES
a

Third Party
Factor to be Verified

b

Written

Oral

c

Documents Provided by
Applicant

Self-Declaration

Verification Tips

• Self-employment, tips,
gratuities, etc.

None available.

None available.

• Form 1040/1040A showing
amount earned and
employment period.

• Notarized statement or
affidavit signed by applicant
showing amount earned and
pay period.

• Social security number.

• None required.

• None required.

• Original Social Security
card
• Driver’s license with SSN
• Identification card issued
by a federal, State, or local
agency, a medical
insurance provider, or an
employer or trade union.
• Earnings statements on
payroll stubs
• Bank statement
• Form 1099
• Benefit award letter
• Retirement benefit letter
• Life insurance policy
• Court records

• Certification that document is
complete/accurate unless
original Social Security card is
provided.

• Individuals who have applied for
legalization under the Immigration
Reform and Control Act of 1986
will be able to disclose their social
security numbers but unable to
supply cards for documentation.
Social security numbers are
assigned to these persons when
they apply for amnesty. The
cards go to DHS until the persons
are granted temporary lawful
resident status. Until that time,
their acceptable documentation is
a letter from the DHS indicating
that social security numbers have
been assigned.

• Unborn children.

• None required.

• None required.

• None required.

• Applicant/tenant self-certifies
to pregnancy.

• Owner may not verify further
than self-certification.

a

NOTE: Requests for verification from third parties must be accompanied by a Consent to Release form.
NOTE: If the original document is witnessed but is a document that should not be copied, the owner should record the type of document, any control or serial numbers, and the
issuer. The owner should also initial and date this notation in the file.
c
NOTE: For all oral verification, file documentation must include facts, time and date of contact, and name and title of third party.
b

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14

HUD Occupancy Handbook
Appendix 3: Acceptable Forms of Verification

Appendix 3

4350.3 REV-1

Appendix 3: Acceptable Forms of Verification
ACCEPTABLE SOURCES
a

Third Party
Factor to be Verified
• Unemployment
compensation.

b

Written

• Verification form
completed by source.

Oral

c

• Telephone or in-person
contact with agency
documented in a file by
an owner.

Documents Provided by
Applicant

Self-Declaration

• Copies of checks or
records from agency
provided by applicant
stating payment amounts
and dates.

• Frequency of payments and
expected length of benefit term
must be verified.
• Income not expected to last full
12 months must be calculated
based on 12 months and interim
recertification completed when
benefits stop.

• Benefit notification letter
signed by authorizing
agency.
• Welfare payments (as-paid
states only).

• Verification form
completed by welfare
department indicating
maximum amount
family may receive.

• Telephone or in-person
contact with income
source, documented in
file by the owner.

• Maximum shelter
allowance schedule with
ratable reduction schedule
provided by applicant.

Verification Tips

• Not appropriate.

• Actual welfare benefit amount
not sufficient as proof of income
in “as-paid” states or localities
since income is defined as
maximum shelter amount.

• Maximum shelter
schedule by household
size with ratable
reduction schedule.

a

NOTE: Requests for verification from third parties must be accompanied by a Consent to Release form.
NOTE: If the original document is witnessed but is a document that should not be copied, the owner should record the type of document, any control or serial numbers, and the
issuer. The owner should also initial and date this notation in the file.
c
NOTE: For all oral verification, file documentation must include facts, time and date of contact, and name and title of third party.
b

HUD Occupancy Handbook
Appendix 3: Acceptable Forms of Verification

15

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4350.3 REV-1

Appendix 3

Appendix 3: Acceptable Forms of Verification
ACCEPTABLE SOURCES
a

Third Party
Factor to be Verified
• Zero Income.

b

Written

• Not applicable.

Oral

c

• Not applicable.

Documents Provided by
Applicant
• Not applicable.

Self-Declaration
• Applicant/Tenant selfcertifies to zero income.

Verification Tips
• Owners may require
applicant/tenant to sign
verification release of information
forms for state, local, and federal
benefits programs, as well as the
HUD 9887 and HUD 9887-A.
• Owners may require the tenant
to reverify zero income status at
least every 90 days.

a

NOTE: Requests for verification from third parties must be accompanied by a Consent to Release form.
NOTE: If the original document is witnessed but is a document that should not be copied, the owner should record the type of document, any control or serial numbers, and the
issuer. The owner should also initial and date this notation in the file.
c
NOTE: For all oral verification, file documentation must include facts, time and date of contact, and name and title of third party.
b

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16

HUD Occupancy Handbook
Appendix 3: Acceptable Forms of Verification

Appendix 4
HUD Model Leases
• Appendix 4-A: Model Lease for Subsidized
Programs (Family Model Lease)
• Appendix 4-B: Model Lease for Section 202/8 or
Section 202 PACs
• Appendix 4-C: Model Lease for Section 202
PRACs
• Appendix 4-D: Model Lease for Section 811
PRACs

Appendix 4-A
Model Lease for Subsidized Programs (Family
Model Lease)

Appendix 4-A

4350.3 REV-1

______________________________________________________________________________________
MODEL LEASE FOR SUBSIDIZED PROGRAMS
1.

Parties and
The parties to this Agreement are ___________
Dwelling
____________________, referred to as the
Unit:
Landlord, and
______________________________(A)____________________________,
referred to as the Tenant. The Landlord leases
to the Tenant unit number _______, located at
__________________________________________________________________
in the project known as__________________________________________.

2.

Length of Time
(Term):

The initial term of this Agreement shall begin
on ____(A)_____ and end on ____(B)_____. After
the initial term ends, the Agreement will
continue for successive terms of one _________(C)______ each unless
automatically terminated as permitted by paragraph 23 of this
Agreement.

3.

Rent:

4.

Changes in the
Tenant's Share
of the Rent:

The Tenant agrees to pay $____(A)_____ for the
partial month ending on ______________. After
that, Tenant agrees to pay a rent of $_(B)_ per
month. This amount is due on the ______(C)____ day of the month at
____________________(D)___________________________________________
__________________________________________________________________.
The Tenant understands that this monthly rent is less than the
market (unsubsidized) rent due on this unit. This lower rent is
available either because the mortgage on this project is subsidized
by the Department of Housing and Urban Development (HUD) and/or
because HUD makes monthly payments to the Landlord on behalf of the
Tenant. The amount, if any, that HUD makes available monthly on
behalf of the Tenant is called the tenant assistance payment and is
shown on the "Assistance Payment" line of the Certification and
Recertification of Tenant Eligibility Form which is Attachment
No. 1 to this Agreement.
The Tenant agrees that the amount of rent the
Tenant pays and/or the amount of assistance that
HUD pays on behalf of the Tenant may be changed
during the term of this Agreement if:

a.

HUD or the Contract Administrator (such as a Public Housing
Agency) determines, in accordance with HUD procedures, that an
increase in rents is needed;

b.

HUD or the Contract Administrator changes any allowance for
utilities or services considered in computing the Tenant's
share of the rent;

c.

the income, the number of persons in the Tenant's household or
other factors considered in calculating the Tenant's rent
change and HUD procedures provide that the Tenant's rent or
assistance payment be adjusted to reflect the change;

d.

changes in the Tenant's rent or assistance payment are required
by HUD's recertification or subsidy termination procedures;

Page 1 of 14

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4350.3 REV-1

Appendix 4-A

e.

HUD's procedures for computing the Tenant's assistance payment
or rent change; or

f.

the Tenant fails to provide information on his/her income,
family composition or other factors as required by the
Landlord.

The Landlord agrees to implement changes in the Tenant's rent or
tenant assistance payment only in accordance with the time frames
and administrative procedures set forth in HUD's handbooks,
instructions and regulations related to administration of
multifamily subsidy programs. The Landlord agrees to give the
Tenant at least 30 days advance written notice of any increase in
the Tenant's rent except as noted in paragraphs 11, 15 or 17. The
Notice will state the new amount the Tenant is required to pay, the
date the new amount is effective, and the reasons for the change in
rent. The Notice will also advise the Tenant that he/she may meet
with the Landlord to discuss the rent change.
5.

Charges for Late
Payments and
Returned Checks:

If the Tenant does not pay the full amount of
the rent shown in paragraph 3 by the end of
the 5th day of the month, the Landlord may
Collect a fee of $5 on the 6th day of the
month. Thereafter, the Landlord may collect $1
for each additional day the rent remains
unpaid during the month it is due.
The Landlord may not terminate this Agreement
for failure to pay late charges, but may
terminate this Agreement for non-payment of rent,
as explained in paragraph 23. The Landlord may
collect a fee of $________ on the second or any
additional time a check is not honored for
payment (bounces). The charges discussed in this
paragraph are in addition to the regular monthly
rent payable by the Tenant.

6.

Condition of
Dwelling
Unit

By signing this Agreement, the Tenant
acknowledges that the unit is safe, clean and
in good condition. The Tenant agrees that all
Appliances and equipment in the unit are in
good working order, except as described on the
Unit Inspection Report which is Attachment
No. 2 to this Agreement. The Tenant also
agrees that the Landlord has made no promises to
decorate, alter, repair or improve the unit,
except as listed on the Unit Inspection Report.

7.

Charges for
Utilities and
Services:

The following charts describe how the cost of
utilities and services related to occupancy
of the unit will be paid. The Tenant agrees
that these charts accurately describe the
utilities and services paid by the Landlord and
those paid by the Tenant.

5/03

Page 2 of 14

Appendix 4-A

4350.3 REV-1

______________________________________________________________________________________
a. The Tenant must pay for the utilities in column (1). Payments
should be made directly to the appropriate utility company.
The items in column (2) are included in the Tenant's rent.
(1)
Put "x" by any
Utility Tenant
pays directly
_________
_________
_________
_________
_________
_________

(2)
Type of
Utility

Put "x" by any
Utility Included
in Tenant Rent

Heat
Lights, Electric
Cooking
Water
Other (Specify.
____________
____________

__________
__________
__________
__________
__________
__________

b. The Tenant agrees to pay the Landlord the amount shown in
column (3) on the date the rent is due. The Landlord certifies
that HUD had authorized him/her to collect the type of charges
shown in column (3) and that the amounts shown in column (3) do
not exceed the amounts authorized by HUD.
(3)
Show $ Amount Tenant
Pays to Landlord in
Addition to Rent
Parking
Other (Specify.)
_______________
_______________
8.

Security Deposits:

$__________
$__________
$__________

The Tenant has deposited $___(A)____ with the
Landlord. The Landlord will hold this
security deposit for the period the Tenant
occupies the unit. After the Tenant has moved
from the unit, the Landlord will determine
whether the Tenant is eligible for a refund of
any or all of the security deposit. The amount
of the refund will be determined in accordance
with the following conditions and procedures.

a. The Tenant will be eligible for a refund of the security
Deposit only if the Tenant provided the Landlord with the 30-day
written notice of intent to move required by paragraph 23,
unless the Tenant was unable to give the notice for reasons
beyond his/her control.
b.

After the Tenant has moved from the unit, the Landlord will
inspect the unit and complete another Unit Inspection Report.
The Landlord will permit the Tenant to participate in the
inspection, if the Tenant so requests.

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4350.3 REV-1

Appendix 4-A

______________________________________________________________________________________
C. The Landlord will refund to the Tenant the amount of the
security deposit plus interest computed at _(B)_%, beginning
___(C)___ ,less any amount needed to pay the cost of:

d.

(1)

unpaid rent;

(2)

damages that are not due to normal wear and tear and are
not listed on the Unit Inspection Report;

(3)

charges for late payment of rent and returned checks, as
described in paragraph 5; and

(4)

charges for unreturned keys, as described in paragraph 9.

The Landlord agrees to refund the amount computed in paragraph
8c within _(D)_ days after the Tenant has permanently moved
out of the unit, returned possession of the unit to the
Landlord, and given his/her new address to the Landlord. The
Landlord will also give the Tenant a written list of charges
that were subtracted from the deposit. If the Tenant
disagrees with the Landlord concerning the amounts deducted
and asks to meet with the Landlord, the Landlord agrees to
meet with the Tenant and informally discuss the disputed
charges.

e. If the unit is rented by more than one person, the Tenants
agree that they will work out the details of dividing any
refund among themselves. The Landlord may pay the refund to
any Tenant identified in Paragraph 1 of this Agreement.
f.

9.

10.

The Tenant understands that the Landlord will not count the
Security Deposit towards the last month's rent or towards
repair charges owed by the Tenant in accordance with
paragraph 11.

Keys and Locks:

The Tenant agrees not to install additional
or different locks or gates on any doors or
windows of the unit without the written
permission of the Landlord. If the Landlord
approves the Tenant's request to install such
locks, the Tenant agrees to provide the
Landlord with a key for each lock. When this
Agreement ends, the Tenant agrees to return
all keys to the dwelling unit to the
Landlord. The Landlord may charge the Tenant
$ ___________ for each key not returned.

Maintenance:
a.

5/03

The Landlord agrees to:
(1)

regularly clean all common areas of the project;

(2)

maintain the common areas and facilities in a safe
condition;

(3)

arrange for collection and removal of trash and garbage;

Page 4 of 14

Appendix 4-A

4350.3 REV-1

______________________________________________________________________________________

b.

(4)

maintain all equipment and appliances in safe and working
order;

(5)

make necessary repairs with reasonable promptness;

(6)

maintain exterior lighting in good working order:

(7)

provide extermination services, as necessary; and

(8)

maintain grounds and shrubs.

The Tenant agrees to:
(1)

keep the unit clean;

(2) use all appliances, fixtures and equipment in a safe
manner and only for the purposes for which they are
intended;

11.

12.

(3)

not litter the grounds or common areas of the project;

(4)

not destroy, deface, damage or remove any part of the
unit, common areas, or project grounds;

(5)

give the Landlord prompt notice of any defects in the
plumbing, fixtures, appliances, heating and cooling
equipment or any other part of the unit or related
facilities; and

(6)

remove garbage and other waste from the unit in a clean
and safe manner.

Damages:

Whenever damage is caused by carelessness,
misuse, or neglect on the part of the Tenant,
his/her family or visitors, the Tenant
agrees to pay:

a.

the cost of all repairs and do so within 30 days after
receipt of the Landlord's demand for the repair charges; and

b.

rent for the period the unit is damaged whether or not the
unit is habitable. The Tenant understands that HUD will not
make assistance payments for any period in which the unit is
not habitable. For any such period, the Tenant agrees to
pay the HUD-approved market rent rather than the Tenant rent
shown in paragraph 3 of this agreement.

Restrictions on
Alterations:

No alteration, addition, or improvements shall
be made in or to the premises without the
prior consent of the Landlord in writing. The
Landlord agrees to provide reasonable
accommodation to an otherwise eligible tenant’s
disability, including making changes to rules,
policies, or procedures, and making and paying
for structural alterations to a unit or common
areas. The Landlord is not required to provide

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4350.3 REV-1

Appendix 4-A

______________________________________________________________________________________
accommodations that constitute a fundamental
alteration to the Landlord’s program or which
would pose a substantial financial and
administrative hardship. See the regulations
at 24 CFR Part 8. In addition, if a requested
structural modification does pose a substantial
financial and administrative hardship, the
Landlord must then allow the tenant to make and
pay for the modification in accordance with the
Fair Housing Act.
13.

14.

15.

General
Restrictions:

The Tenant must live in the unit and the
unit must be the Tenant's only place of
residence. The Tenant shall use the
premises only as a private dwelling for
himself/herself and the individuals listed on
the Certification and Recertification of Tenant
Eligibility. The Tenant agrees to permit other
individuals to reside in the unit only after
obtaining the prior written approval of the
Landlord. The Tenant agrees not to:

a.

sublet or assign the unit, or any part of the unit;

b.

use the unit for unlawful purposes;

c.

engage in or permit unlawful activities in the unit, in the
common areas or on the project grounds;

d.

have pets or animals of any kind in the unit without the prior
written permission of the Landlord, but the landlord will
allow the tenant to keep an animal needed as a reasonable
accommodation to the tenant’s disability, and will allow
animals to accompany visitors with disabilities who need such
animals as an accommodation to their disabilities; or

e.

make or permit noises or acts that will disturb the rights or
comfort of neighbors. The Tenant agrees to keep the volume
of any radio, phonograph, television or musical instrument at
a level which will not disturb the neighbors.

Rules:

The Tenant agrees to obey the House Rules which are
Attachment No. 3 to this Agreement. The tenant agrees
to obey additional rules established after the effective
date of this Agreement if:

a.

the rules are reasonably related to the safety, care and
cleanliness of the building and the safety, comfort and
convenience of the Tenants; and

b.

the Tenant receives written notice of the proposed rule at
least 30 days before the rule is enforced.

Regularly Scheduled
Recertifications:

5/03

Every year around the __(A)___ day of _____
(B)__, the Landlord will request the
Tenant to report the income and composition

Page 6 of 14

Appendix 4-A

4350.3 REV-1

______________________________________________________________________________________
of the Tenant's household and to supply any
other information required by HUD for the
purposes of determining the Tenant's rent
and assistance payment, if any. The Tenant
agrees to provide accurate statements of
this information and to do so by the date
specified in the Landlord's request. The
landlord will verify the information
supplied by the Tenant and use the verified
information to recompute the amount of the
Tenant's rent and assistance payment, if
any.
a.

If the Tenant does not submit the required recertification
information by the date specified in the Landlord's request,
the Landlord may impose the following penalties. The
Landlord may implement these penalties only in accordance
with the administrative procedures and time frames specified
in HUD's regulations, handbooks and instructions related to
the administration of multifamily subsidy programs.
(1)

Require the Tenant to pay the higher, HUD-approved
market rent for the unit.

(2) Implement any increase in rent resulting from the
recertification processing without providing the 30-day
notice otherwise required by paragraph 4 of this
Agreement.
b.

16.

The Tenant may request to meet with the Landlord to discuss
any change in rent or assistance payment resulting from the
recertification processing. If the Tenant requests such a
meeting, the Landlord agrees to meet with the Tenant and
discuss how the Tenant's rent and assistance payment, if any,
were computed.

Reporting Changes Between Regularly Scheduled
Recertifications:
a.

b.

If any of the following changes occur, the Tenant agrees
to advise the Landlord immediately.
(1)

Any household member moves out of the unit.

(2)

An adult member of the household who was reported
as unemployed on the most recent certification or
recertification obtains employment.

(3)

The household's income cumulatively increases by
$200 or more a month.

The Tenant may report any decrease in income or any
change in other factors considered in calculating the
Tenant's rent. Unless the Landlord has confirmation
that the decrease in income or change in other factors
will last less than one month, the Landlord will verify
the information and make the appropriate rent reduction.

Page 7 of 14

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4350.3 REV-1

Appendix 4-A

______________________________________________________________________________________
However, if the Tenant's income will be partially or
fully restored within two months, the Landlord may delay
the certification process until the new income is known,
but the rent reduction will be retroactive and the
Landlord may not evict the Tenant for nonpayment of rent
due during the period of the reported decrease and the
completion of the certification process. The Tenant has
thirty days after receiving written notice of any rent
due for the above described time period to pay or the
Landlord can evict for nonpayment of rent. (Revised
3/22/89)

17.

c.

If the Tenant does not advise the Landlord of these
interim changes, the Landlord may increase the Tenant's
rent to the HUD-approved market rent. The Landlord may
do so only in accordance with the time frames and
administrative procedures set forth in HUD's
regulations, handbooks and instructions on the
administration of multifamily subsidy programs.

d.

The Tenant may request to meet with the Landlord to
discuss how any change in income or other factors
affected his/her rent or assistance payment, if any.
If the Tenant requests such a meeting, the Landlord
agrees to meet with the Tenant and explain how the
Tenant's rent or assistance payment, if any, was
computed.

Removal of Subsidy:
a.

The Tenant understands that assistance made available
on his/her behalf may be terminated if events in either
items 1 or 2 below occur. Termination of assistance
means that the Landlord may make the assistance
available to another Tenant and the Tenant's rent will
be recomputed. In addition, if the Tenant's assistance
is terminated because of criterion (1) below, the
Tenant will be required to pay the HUD-approved market
rent for the unit.
(1)The Tenant does not provide the Landlord with
the information or reports required by
paragraph 15 or 16 within 10 calendar days
after receipt of the Landlord's notice of
intent to terminate the Tenant's assistance
payment.
(2)The amount the Tenant would be required to pay
towards rent and utilities under HUD rules and
regulations equals the Family Gross Rent shown on
Attachment 1.

b.

5/03

The Landlord agrees to give the Tenant written notice
of the proposed termination. The notice will advise
the Tenant that, during the ten calendar days following
the date of the notice, he/she may request to meet with
the Landlord to discuss the proposed termination of

Page 8 of 14

Appendix 4-A

4350.3 REV-1

______________________________________________________________________________________
assistance. If the Tenant requests a discussion of the
proposed termination, the Landlord agrees to meet with
the Tenant.
c.

Termination of assistance shall not affect the Tenant's
other rights under this Agreement, including the right
to occupy the unit. Assistance may subsequently be
reinstated if the Tenant submits the income or other
data required by HUD procedures, the Landlord
determines the Tenant is eligible for assistance, and
assistance is available.

18.

Tenant
Obligation
To Repay:

If the tenant submits false information on
any application, certification or request
for interim adjustment or does not report
interim changes in family income or other
factors as required by paragraph 16 of this
Agreement, and as a result, is charged a rent less
than the amount required by HUD's rent formulas,
the Tenant agrees to reimburse the Landlord for the
difference between the rent he/she should have paid
and the rent he/she was charged. The Tenant is
not required to reimburse the Landlord for
undercharges caused solely by the Landlord's
failure to follow HUD's procedures for computing
rent or assistance payments.

19.

Size of
Dwelling

The Tenant understands that HUD requires the
Landlord to assign units according to the
size of the household and the age and sex of
the household members. If the Tenant is or becomes
eligible for a different size unit, and the
required size unit becomes available, the Tenant
agrees to:

20.

a.

move within 30 days after the Landlord notifies him/her that
unit of the required size is available within the project; or

b.

remain in the same unit and pay the HUD-approved market rent.

Access by
Landlord:

The Landlord agrees to enter the unit only
during reasonable hours, to provide
reasonable advance notice of his/her intent
to enter the unit, and to enter the unit only
after receiving the Tenant's consent to do so,
except when urgency situations make such notices
impossible or except under
paragraph (c) below.

a.

The Tenant agrees to permit the Landlord, his/her agents or
other persons, when authorized by the Landlord, to enter the
unit for the purpose of making reasonable repairs and
periodic inspections.

b.

After the Tenant has given a notice of intent to move, the
Tenant agrees to permit the Landlord to show the unit to
prospective tenants during reasonable hours.

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4350.3 REV-1

Appendix 4-A

______________________________________________________________________________________
c.

If the Tenant moves before this Agreement ends, the Landlord
may enter the unit to decorate, remodel, alter or otherwise
prepare the unit for re-occupancy.

21.

Discrimination
Prohibited:

The Landlord agrees not to discriminate
based upon race, color, religion, creed,
National origin, sex, age, familial status,
and disability.

22.

Change in Rental
Agreement:

The Landlord may, with the prior approval of
HUD, change the terms and conditions of this
Agreement. Any changes will become
effective only at the end of the initial
term or a successive term. The Landlord must
notify the Tenant of any change and must
offer the Tenant a new Agreement or an
amendment to the existing Agreement. The
Tenant must receive the notice at least 60
days before the proposed effective date
of the change. The Tenant may accept the
changed terms and conditions by signing the
new Agreement or the amendment to the
existing Agreement and returning it to the
Landlord. The Tenant may reject the changed
terms and conditions by giving the
Landlord written notice that he/she intends
to terminate the tenancy. The Tenant must
give such notice at least 30 days before the
proposed change will go into effect. If the
Tenant does not accept the amended agreement,
the Landlord may require the Tenant to move
from the project, as provided in paragraph
23.

23.

Termination of
Tenancy:
a.

To terminate this Agreement, the Tenant must give the
Landlord 30-days written notice before moving from the unit.
If the Tenant does not give the full 30-day notice, the
Tenant shall be liable for rent up to the end of the 30 days
for which notice was required or to the date the unit is rerented, whichever date comes first.

b.

Any termination of this Agreement by the Landlord must be
carried out in accordance with HUD regulations, State and
local law, and the terms of this Agreement.

c.

The Landlord may terminate this Agreement for the following
reasons:

5/03

1.

the Tenant’s material noncompliance with the terms of
this Agreement;

2.

the Tenant’s material failure to carry out obligations
under any State Landlord
Page 10 of 14

Appendix 4-A

4350.3 REV-1

______________________________________________________________________________________
and Tenant Act;
3.

drug related criminal activity engaged in on or near
the premises, by any tenant, household member, or
guest, and any such activity engaged in on the
premises by any other person under the tenant’s
control;

4.

determination made by the Landlord that a household
member is illegally using a drug;

5.

determination made by the Landlord that a pattern of
illegal use of a drug interferes with the health,
safety, or right to peaceful enjoyment of the
premises by other residents;

6.

criminal activity by a tenant, any member of the
tenant’s household, a guest or another person under the
tenant’s control:
(a) that threatens the health, safety, or right to
peaceful enjoyment of the premises by other
residents (including property management staff
residing on the premises); or
(b) that threatens the health, safety, or right to
peaceful enjoyment of their residences by persons
residing in the immediate vicinity of the
premises;

7.

if the tenant is fleeing to avoid prosecution, or
custody or confinement after conviction, for a crime,
or attempt to commit a crime, that is a felony under
the laws of the place from which the individual flees,
or that in the case of the State of New Jersey, is a
high misdemeanor;

8.

if the tenant is violating a condition of probation or
parole under Federal or State law;

9.

determination made by the Landlord that a household
member’s abuse or pattern of abuse of alcohol threatens
the health, safety, or right to peaceful enjoyment of
the premises by other residents;

10. if the Landlord determines that the tenant, any member
of the tenant’s household, a guest or another person
under the tenant’s control has engaged in the criminal
activity, regardless of whether the tenant, any member
of the tenant’s household, a guest or another person
under the tenant’s control has been arrested or
convicted for such activity.

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4350.3 REV-1

Appendix 4-A

______________________________________________________________________________________
d. The Landlord may terminate this Agreement for other good
cause, which includes, but is not limited to, the tenant’s
refusal to accept change to this agreement. Terminations for
“other good cause” may only be effective as of the end of any
initial or successive term.
The term material noncompliance with the lease includes:
(1)
one or more substantial violations of the lease; (2) repeated
minor violations of the lease that (a) disrupt the livability of
the project; (b) adversely affect the health or safety of any
person or the right of any tenant to the quiet enjoyment to the
leased premises and related project facilities, (c) interfere
with the management of the project, or (d) have an adverse
financial effect on the project (3) failure of the tenant to
timely supply all required information on the income and
composition, or eligibility factors, of the tenant household
(including, but not limited to, failure to meet the disclosure
and verification requirements for Social Security Numbers, or
failure to sign and submit consent forms for the obtaining of
wage and claim information from State Wage Information Collection
Agencies), and (4) Non-payment of rent or any other financial
obligation due under the lease beyond any grace period permitted
under State law. The payment of rent or any other financial
obligation due under the lease after the due date but within the
grace period permitted under State law constitutes a minor
violation.
e.

5/03

If the Landlord proposes to terminate this Agreement, the
Landlord agrees to give the Tenant written notice and the
grounds for the proposed termination. If the Landlord is
terminating this agreement for “other good cause,” the
termination notice must be mailed to the Tenant and handdelivered to the dwelling unit in the manner required by HUD
at least 30 days before the date the Tenant will be required
to move from the unit and in accordance with State law
requirements. Notices of proposed termination for other
reasons must be given in accordance with any time frames set
forth in State and local law. Any HUD-required notice period
may run concurrently with any notice period required by State
or local law. All termination notices must:
•

specify the date this Agreement will be terminated;

•

state the grounds for termination with enough detail for
the Tenant to prepare a defense;

•

advise the Tenant that he/she has 10 days within which to
discuss the proposed termination of tenancy with the
Landlord. The 10-day period will begin on the earlier of
the date the notice was hand-delivered to the unit or the
day after the date the notice is mailed. If the Tenant
requests the meeting, the Landlord agrees to discuss the
proposed termination with the Tenant; and

•

advise the Tenant of his/her right to defend the action in
court.

Page 12 of 14

Appendix 4-A

4350.3 REV-1

______________________________________________________________________________________
f.

If an eviction is initiated, the Landlord agrees to rely
only upon those grounds cited in the termination notice
required by paragraph e.

24.

Hazards:

The Tenant shall not undertake, or permit his/her
family or guests to undertake, any hazardous acts
or do anything that will increase the project's
insurance premiums. Such action constitutes a
material non-compliance. If the unit is damaged by
fire, wind, or rain to the extent that the unit
cannot be lived in and the damage is not caused or
made worse by the Tenant, the Tenant will be
responsible for rent only up to the date of the
destruction. Additional rent will not accrue until
the unit has been repaired to a livable condition.

25.

Penalties for
Submitting False
Information:

Knowingly giving the Landlord false
information regarding income or other
factors considered in determining
Tenant's eligibility and rent is a
material noncompliance with the lease
subject to termination of tenancy. In
addition, the Tenant could become subject to
penalties available under Federal law.
Those penalties include fines up to $10,000
and imprisonment for up to five years.

26.

Contents of this
Agreement:

This Agreement and its Attachments make
up the entire agreement between the
Landlord and the Tenant regarding the unit.
If any Court declares a particular provision
of this Agreement to be invalid or illegal,
all other terms of this Agreement will remain
in effect and both the Landlord and the
Tenant will continue to be bound by them.

27.

Attachments to
the Agreement:

The Tenant certifies that he/she has
received a copy of this Agreement and the
following Attachments to this Agreement
and understands that these Attachments are
part of this Agreement.

a. Attachment No. 1 - Certification and Recertification of
Tenant Eligibility. (59 Certification)
b. Attachment No. 2 - Unit Inspection Report.
c. Attachment No. 3 - House Rules (if any).
28.

Tenants’ rights to organize: Landlord agrees to allow tenant
and tenant organizers to conduct on the property the activities
related to the establishment or operation of a tenant
organization set out in accordance with HUD requirements.

29.

Tenant Income Verification: The Tenant must promptly provide the
Landlord with any letter or other notice by HUD to a member of

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4350.3 REV-1

Appendix 4-A

______________________________________________________________________________________
the family that provides information concerning the amount or
verification of family income in accordance with HUD
requirements.
30.

The lease agreement will terminate automatically, if the Section
8 Housing Assistance contract terminates for any reason.

31. Signatures:
TENANT
BY:
1. _________________________________________

_____/____/____
Date Signed

2. __________________________________________

____/____/____
Date Signed

3. __________________________________________

____/____/____
Date Signed

LANDLORD
BY:
1. _________________________________________

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Page 14 of 14

____/____/____
Date Signed

Appendix 4-B
Model Lease for Section 202/8
or Section 202 PACs

4350.3 REV-1

Appendix 4-B

______________________________________________________________________________________
DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT
____________________________
Project Name
____________________________
HUD Project Number
Model Lease For Use Under:
(1) The Section 202 Program of Housing for the Elderly or Handicapped in conjunction with the
Section 8 Housing Assistance Payments Program; and (2) the Section 202 Program for
Nonelderly Handicapped Families and Individuals in conjunction with Section 162 assistance and
Project Assistance Contracts.
This agreement made and entered into this _______ day of ___________, 20__, between
_____________________________________________________, as LANDLORD, and
_________________________________________________________, as TENANT.
WITNESSETH
WHEREAS, the LANDLORD is the Mortgagor under a Mortgage covering the project in which the
hereinafter described unit is situated, which secures a loan made by the Secretary of Housing
and Urban Development (HUD)(hereinafter "Secretary") pursuant to Section 202 of the Housing
Act of 1959, as amended, and
WHEREAS, the LANDLORD has entered into a Housing Assistance Payments (HAP) Contract
with the Secretary, or the LANDLORD has entered into a Project Assistance Contract (PAC) with
the Secretary, (STRIKE INAPPLICABLE CONTRACT), and
WHEREAS, pursuant to a Regulatory Agreement entered into between the LANDLORD and the
Secretary, the LANDLORD has agreed to limit occupancy of the project to elderly or handicapped
families and individuals as defined in Section 202 of the Housing Act of 1959, as amended, and
applicable HUD regulations under criteria for eligibility of TENANTS for admission to Section 8
assisted units and conditions of continued occupancy in accordance with the terms and
provisions of the HAP Contract, or applicable HUD regulations under criteria for eligibility of
TENANTS for admission to Section 162 assisted units and conditions of continued occupancy in
accordance with the terms and provisions of the PAC, (STRIKE INAPPLICABLE
REGULATIONS); and
WHEREAS, the LANDLORD has determined that the TENANT is eligible to pay less than the
contract rent for the described unit,
NOW THEREFORE,
1.

The LANDLORD leases to the TENANT, and the TENANT leases from the

LANDLORD dwelling unit in the project known as
_________________________________________________________________
for a term of one year commencing on the _____ day of ________________________________,
20__,
and ending on the _____ day of ________________________________, 20__.

Page 1 of 9

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Appendix 4-B

4350.3 REV-1

______________________________________________________________________________________
2. The total rent (Contract Rent) shall be $____________ per month.
3. The total rent specified in Paragraph 2, above, shall include the following utilities:
__________________________________ _______________________________________
__________________________________ _______________________________________
(If the total rent includes all utilities, enter "ALL"; where TENANTS pay some or all utilities, enter
the following additional paragraph as 3a.)
The total rent stipulated herein does not include the cost of the following utility service(s), for
which the Utility Allowance is $________________:
__________________________________ _______________________________________
__________________________________ _______________________________________
Charges for such service(s) is/are to be paid directly by the TENANT to the utility
company/companies providing such service(s). If the Utility Allowance exceeds the required
TENANT's share of the total housing expense per HUD-approved schedule and criteria, the
LANDLORD shall pay the TENANT the amount of such excess on behalf of the Government
upon receipt of funds
from HUD for that purpose. (Note: Utility Allowance is not applicable to non-Section 8 tenants.)
4. Where meal service is a condition of occupancy, the charge for such meals shall be
$________ per month, and a mandatory meals agreement will be made a part of this lease.
5. Of the total rent, $___________ shall be payable by or at the direction of HUD as housing
assistance payments, or project assistance payments (STRIKE INAPPLICABLE PAYMENTS) on
behalf of the TENANT, and $_____ shall be payable by the TENANT. These amounts shall be
subject to change by reason of changes in HUD requirements, changes in the TENANT's family
income, family composition, or extent of exceptional medical or other unusual expenses in
accordance with HUD-established schedules and criteria; or by reason of adjustment by HUD of
any applicable Utility Allowance. Any such change shall be effective as of the date stated in a
Notice to the TENANT. (Note: This paragraph is not applicable to non-Section 8 tenants.)
6. The TENANT's share of the rent shall be due and payable on or before the first day of each
month at ___________________ to the LANDLORD, or to such other person or persons or at
such places as the LANDLORD may from time to time designate in writing.
7. A security deposit equal to one month's total tenant payment or $50, whichever is greater,
shall be required at the time of execution of this Agreement. Accordingly, TENANT hereby
makes a deposit of $__________________ against any damage except reasonable wear done to
the premises by the TENANT, his/her family, guests, or agents; and agrees to pay when billed the
full amount of any such damage in order that the deposit will remain intact. Upon termination of
this Lease, the deposit is to be refunded to the TENANT or to be applied to any such damage or
any rent delinquency. The LANDLORD shall comply with all State and local laws regarding
interest payments on security deposits.
8. The LANDLORD shall not discriminate against the TENANT in the provision of services or
in any other manner on the grounds of race, color, creed, religion, sex, familial status, national
origin, or disability.

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Page 2 of 9

4350.3 REV-1

Appendix 4-B

______________________________________________________________________________________
9. Unless terminated or modified as provided herein, this Agreement shall be automatically
renewed for successive terms of one month each at the aforesaid rental, subject to adjustment as
herein provided.
(a) The TENANT may terminate this Agreement at the end of the initial term or any successive
term by giving 30 days written notice in advance to the LANDLORD. Whenever the LANDLORD
has been in material noncompliance with this Agreement, the TENANT may in accordance with
State law terminate this Agreement by so advising the LANDLORD in writing.
(b) The LANDLORD's right to terminate this Agreement is governed by the regulation at 24
CFR Part 247. The HUD Regulation provides that the LANDLORD may terminate this Agreement
only under the following circumstances:
(1) The LANDLORD may terminate, effective at the end of the initial term or any successive
term, by giving the TENANT notification in the manner prescribed in paragraph (g) below that the
term of this Agreement is not renewed and this Agreement is accordingly terminated. This
termination must be based upon either material noncompliance with this Agreement, material
failure to carry out obligations under any State landlord or tenant act, or other good cause. When
the termination of the tenancy is based on other good cause, the termination notice shall so state,
at the end of a term and in accordance with the termination provisions of this Agreement, but in
no case earlier than 30 days after receipt by the TENANT of the notice. Where the termination
notice is based on material noncompliance with this Agreement or material failure to carry out
obligations under a State landlord and tenant act, the time of service shall be in accordance with
the previous sentence or State law, whichever
is later.
(2) Notwithstanding subparagraph (1), whenever the TENANT has been in material
noncompliance with this Agreement, the LANDLORD may, in accordance with State law and the
HUD Regulation, terminate this Agreement by notifying the TENANT in the manner prescribed in
paragraph (g) below.
(c) If the TENANT does not vacate the premises on the effective date of the termination of this
Agreement, the LANDLORD may pursue all judicial remedies under State or local law for the
eviction of the TENANT, and in accordance with the requirements in the HUD Regulation.
(d) The term "material noncompliance with this Agreement" shall, in the case of the TENANT,
include (1) one or more substantial violations of this Agreement, (2) repeated minor violations of
this Agreement which disrupt the livability of the project, adversely affect the health or safety of
any person or the right of any tenant to the quiet enjoyment of the leased premises and related
project facilities, interfere with the management of the project or have an adverse financial effect
on the project, or (3) failure of the TENANT to timely supply all required information on the
income and composition, or eligibility factors of the TENANT household (including failure to meet
the disclosure and verification requirements for Social Security Numbers, as provided by 24 CFR
Part 5, or knowingly providing incomplete or inaccurate information). Nonpayment of rent or any
other financial obligation due under this Agreement
(including any portion thereof) beyond any grace period permitted under State law shall constitute
a substantial violation. The payment of rent or any other financial obligation due under this
Agreement after the due date but within any grace period permitted under State law shall
constitute a minor violation.
(e) The conduct of the TENANT cannot be deemed other good cause unless the LANDLORD
has given the TENANT prior notice that said conduct shall henceforth constitute a basis for
termination of this Agreement. Said notice shall be served on the TENANT in the manner
prescribed in paragraph (g) below.

Page 3 of 9

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Appendix 4-B

4350.3 REV-1

______________________________________________________________________________________
(f) The LANDLORD's determination to terminate this Agreement shall be in writing and shall
(1) state that the Agreement is terminated on a date speciified therein, (2) state the reasons for
the LANDLORD's action with enough specificity so as to enable the TENANT to prepare a
defense, (3) advise the TENANT that if he or she remains in the leased unit on the date specified
for termination, the LANDLORD may seek to enforce the termination only by bringing a judicial
action at which time the TENANT may present a defense, and (4) be served on the TENANT in
the manner prescribed by paragraph (g) below.
(g) The LANDLORD's termination notice shall be accomplished by (1) sending a letter by first
class mail, properly stamped and addressed, to the TENANT at his/her address at the project,
with a proper return address, and (2) serving a copy of said notice on any adult person answering
the door at the leased dwelling unit, or if no adult responds, by placing the notice under or
through the door, if possible, or else by affixing the notice to the door. Service shall not be
deemed effective until both notices provided for herein have been accomplished. The date on
which the notice shall be deemed to be received by the TENANT shall be the date on which the
first class letter provided for in clause (1) herein is mailed, or the date on which the notice
provided for in clause (2) is properly given, whichever is later.
(h) The LANDLORD may, with the prior approval of HUD, modify the terms and conditions of
the Agreement, effective at the end of the initial term or a successive term, by serving an
appropriate notice on the TENANT, together with the tender of a revised Agreement or an
addendum revising the existing Agreement. Any increase in rent shall in all cases be governed
by 24 CFR Part 245 and other applicable HUD regulations. This notice and tender shall be
served on the TENANT in the manner prescribed in paragraph (g) and must be received by the
TENANT (as defined in paragraph (g)) at least 30 days prior to the last date on which the
TENANT has the right to terminate the tenancy without being bound by the codified terms and
conditions. The TENANT may accept it by executing the tendered revised Agreement or
addendum, or may reject it by giving the LANDLORD written notice at least 30 days prior to its
effective date that he/she intends to terminate the tenancy. The TENANT's termination notice
shall be
accomplished by sending a letter by first class mail, properly stamped and addressed to the
LANDLORD at his/her address.
(i) The Landlord may terminate this Agreement for the following reasons:
1. drug related criminal activity engaged in on or near the premises, by any tenant,
household member, or guest, and any such activity engaged in on the premises by any other
person under the tenant’s control;
2. determination made by the Landlord that a household member is illegally using a drug;
3. determination made by the Landlord that a pattern of illegal use of a drug interferes with
the health, safety, or right to peaceful enjoyment of the premises by other residents;
4. criminal activity by a tenant, any member of the tenant’s
household, a guest or another person under the tenant’s control:
(a) that threatens the health, safety, or right to peaceful enjoyment of the premises by
other residents (including property management staff residing on the premises); or
(b) that threatens the health, safety, or right to peaceful enjoyment of their residences by
persons residing in the immediate vicinity of the premises;

5/03

Page 4 of 9

4350.3 REV-1

Appendix 4-B

______________________________________________________________________________________
5. if the tenant is fleeing to avoid prosecution, or custody or confinement after conviction,
for a crime, or attempt to commit a crime, that is a felony under the laws of the place from which
the individual flees, or that in the case of the State of New Jersey, is a high misdemeanor; or
6. if the tenant is violating a condition of probation or parole under Federal or State law;
7. determination made by the Landlord that a household member’s abuse or pattern of
abuse of alcohol threatens the health, safety, or right to peaceful enjoyment of the premises by
other residents;
8. if the Landlord determines that the tenant, any member of the tenant’s household, a
guest or another person under the tenant’s control has engaged in criminal activity, regardless of
whether the tenant, any member of the tenant’s household, a guest or another person under the
tenant’s control has been arrested or convicted for such activity.
10. TENANT agrees that the family income, family composition and other eligibility
requirements shall be deemed substantial and material obligations of his/her tenancy with respect
to the amount of rental he/she will be obligated to pay and his/her right of occupancy, and that a
recertification of income shall be made to the LANDLORD annually from the date of this lease in
accordance with HUD regulations and requirements. (Note: This paragraph is not applicable to
non-Section 8 tenants.)
11. TENANT agrees that the TENANT's share of the monthly rental payment is subject to
adjustment by the LANDLORD to reflect income changes which are disclosed on any of
TENANT's recertification of income, and TENANT agrees to be bound by such adjustment.
LANDLORD agrees to give 30 days written notice of any such adjustment to the TENANT, by an
addendum to be made a part of this lease, stating the amount of the adjusted monthly rental
which the TENANT will be required to pay. (Note: This paragraph is not applicable to nonSection 8 tenants.)
12. LANDLORD and TENANT agree that if, upon recertification, TENANT'S income is found
to be sufficient to pay the Contract Rent plus any Utility Allowance, the TENANT shall then be
required to bear the cost of all such housing expense, but he/she will no longer be required to
make income certifications under this lease.
13. The TENANT shall not assign this lease, sublet the premises, give accommodation to any
roomers or lodgers, or permit the use of the premises for any purpose other than as a private
dwelling solely for the TENANT and his/her family. The TENANT agrees to reside in this unit and
agrees that this unit shall be the TENANT's and his/her family's only place of residence.
14. TENANT agrees to pay to the LANDLORD any rental which should have been paid but for
(a) TENANT's misrepresentation in his/her initial income certification or recertification, or in any
other information furnished to the LANDLORD or (b) TENANT's failure to supply income
recertification when required or to supply information requested by the LANDLORD.
15. TENANT for himself/herself and his/her heirs, executors and administrators agrees as
follows:
(a) To pay the rent herein stated promptly when due, without any deductions whatsoever, and
without any obligation on the part of the LANDLORD to make any demand for the same;
(b) To keep the premises in a clean and sanitary condition, and to comply with all obligations
imposed upon TENANTS under applicable provisions of building and housing codes materially
affecting health and safety with respect to said premises and appurtenances, and to save the
LANDLORD harmless from all fines, penalties and costs for violations or noncompliance by

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Appendix 4-B

4350.3 REV-1

______________________________________________________________________________________
TENANT with any of said laws, requirements or regulations, and from all liability arising out of any
such violations or noncompliance.
(c) Not to use premises for any purpose deemed hazardous by insurance companies carrying
insurance thereon;
(d) That if any damage to the property shall be caused by his/her acts or neglect, the TENANT
shall forthwith repair such damage at his/her own expense, and should the TENANT fail or refuse
to make such repairs within a reasonable time after the occurrence of such damage, the
LANDLORD may, at his/her option, make such repairs and charge the cost thereof to the
TENANT, and the TENANT shall thereupon reimburse the LANDLORD for the total cost of the
damages so caused;
(e) To permit the LANDLORD, or his/her agents, or any representative of any holder of a
mortgage on the property, or when authorized by the LANDLORD, the employees of any
contractor, utility company, municipal agency or others, to enter the premises for the purpose of
making reasonable inspections and repairs and replacements;
(f) Not to install a washing machine, clothes dryer, or air conditioning unit in the apartment
without the prior approval of the LANDLORD; and
(g) To permit the LANDLORD or his/her agents to bring appropriate legal action in the event of
a breach or threatened breach by the TENANT of any of the covenants or provisions of this lease.
16. The TENANT is permitted to keep common household pets in his/her dwelling unit
(subject to the provisions in 24 CFR Part 5 and the pet rules promulgated under 24 CFR Part 5).
Any pet rules promulgated by the LANDLORD are attached hereto and incorporated hereby. The
TENANT agrees to comply with these rules. A violation of these rules may be grounds for
removal of the pet or termination of the TENANT's (pet owner's) tenancy (or
both), in accordance with the provisions of 24 CFR Part 5 and applicable regulations and State or
local law. These regulations include 24 CFR Part 5 (Evictions From Certain Subsidized and
HUD-Owned Projects) and provisions governing the termination of tenancy under the Section 8
housing assistance payments and project assistance payments programs.
Note: The Part 5 Pet Rules do not apply to an animal used by a Tenant or visitor that is
needed as a reasonable accommodation for the Tenant or visitor’s disability. Optional: The
LANDLORD may after reasonable notice to the TENANT and during reasonable hours, enter and
inspect the premises. Entry and inspection is permitted only if the LANDLORD has received a
signed, written complaint alleging (or the LANDLORD has reasonable grounds to believe) that the
conduct or condition of a pet in the dwelling unit constitutes, under
applicable State or local law, a nuisance or a threat to the health or safety of the occupants of the
project or other persons in the community where the project is located.
If there is no State or local authority (or designated agent of such an authority) authorized
under applicable State or local law to remove a pet that becomes vicious, displays symptoms of
severe illness, or demonstrates other behavior that constitutes an immediate threat to the health
or safety of the tenancy as a whole, the LANDLORD may enter the premises (if necessary),
remove the pet, and take such action with respect to the pet as may be permissible under State
and local law, which may include placing it in a facility that will provide care and shelter for a
period not to exceed 30 days. The LANDLORD shall enter the premises and
remove the pet or take such other permissible action only if the LANDLORD requests the
TENANT (pet owner) to remove the pet from the project immediately, and the TENANT (pet
owner) refuses to do so, or if the LANDLORD is unable to contact the TENANT (pet owner) to
make a removal request. The cost of the animal care facility shall be paid as provided in 24 CFR
Part 5.

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4350.3 REV-1

Appendix 4-B

______________________________________________________________________________________
17. The LANDLORD agrees to comply with the requirement of all applicable Federal, State,
and local laws, including health, housing and building codes and to deliver and maintain the
premises in safe, sanitary and decent condition.
18. The TENANT, by the execution of this Agreement, agrees that the dwelling unit described
herein has been inspected by him/her and meets with his/her approval. The TENANT
acknowledges hereby that said premises have been satisfactorily completed and that the
LANDLORD will not be required to repaint, replaster, or otherwise perform any other work, labor,
or service which it has already performed for the TENANT. The TENANT admits that he/she has
inspected the unit and found it to be in good and tenantable condition, and agrees that at the end
of the occupancy hereunder to deliver up and surrender said premises to the LANDLORD in as
good condition as when received, reasonable wear and tear excepted.
19. No alteration, addition, or improvements shall be made in or to the premises without the
prior consent of the LANDLORD in writing. The LANDORD agrees to provide reasonable
accommodation to an otherwise eligible tenant’s disability, including making changes to rules,
policies, or procedures, and making and paying for structural alterations to a unit or common
areas. The Landlord is not required to provide accommodations that constitute a fundamental
alteration to the Landlord’s program or which would pose a substantial financial and
administrative hardship. See the regulations at 24 CFR Part 8. In addition, if a requested
structural modification does pose a substantial financial and administrative hardship, the Landlord
must then allow the tenant to make and pay for the modification in accordance with the Fair
Housing Act.
20. TENANT agrees not to waste utilities furnished by the LANDLORD; not to use utilities or
equipment for any improper or unauthorized purpose; and not to place fixtures, signs, or fences in
or about the premises without the prior permission of the LANDLORD in writing. If such
permission is obtained, TENANT agrees, upon termination of the lease, to remove any fixtures,
signs or fences, at the option of the LANDLORD, without damage to the premises.
21. This Agreement shall be subordinate in respect to any mortgages that are now on or that
hereafter may be placed against said premises, and the recording of such mortgage or
mortgages shall have preference and precedence and be superior and prior in lien to this
Agreement, and the TENANT agrees to execute any such instrument without cost, which may be
deemed necessary or desirable to further effect the subordination of this Agreement to any such
mortgage or mortgages and a refusal to execute such instruments shall entitle the LANDLORD,
or the LANDLORD's assigns and legal representatives to the option of cancelling this Agreement
without incurring any expense or damage, and the term hereby granted is expressly limited
accordingly.
22. Tenant Income Verification: The Tenant must promptly provide the Landlord with any
letter or other notice by HUD to a member of the family that provides information concerning the
amount or verification of family income. in accordance with HUD requirements.
23. Tenants’ rights to organize: Landlord agrees to allow tenant and tenant organizers to
conduct on the property the activities related to the establishment or operation of a tenant
organization set out in accordance with HUD requirements.
24. Interim recertifications.
(a) The TENANT agrees to advise the Landlord immediately if any of the following changes
occur.

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Appendix 4-B

4350.3 REV-1

______________________________________________________________________________________
1. Any household member moves out of the unit.
2. Any adult member of the household who was reported as unemployed on the most
recent certification or recertification obtains employment.
3. The household’s income cumulatively increases by $200 or more a month.
(b) The Tenant may report any decrease in income or any change in other factors
considered in calculating the Tenant’s rent. Unless the Landlord has confirmation that the
decrease in income or change in other factors will last less than one month, the Landlord will
verify the information and make the appropriate rent reduction. However, if the Tenant’s income
will be partially or fully restored within two months, the Landlord may delay the certification
process until the new income is known, but the rent reduction will be retroactive and Landlord
may not evict the Tenant for nonpayment of rent due during the period of the reported decrease
and the completion of the certification process. The Tenant has thirty days after receiving written
notice of any rent due for the above described time period to pay or the Landlord can evict for
nonpayment of rent.
(c) If the Tenant does not advise the Landlord of the interim changes concerning household
members or increase in income, the Landlord may increase the Tenant’s rent to the HUDapproved market rent. The Landlord may do so only in accordance with the time frames and
administrative procedures set forth in HUD’s regulations, handbooks and instructions on the
administration of multifamily subsidy programs.
(d) The Tenant may request to meet with the Landlord to discuss how any change in income
or other factors affected his/her rent or assistance payment, if any. If the Tenant requests such a
meeting, the Landlord agrees to meet with the Tenant and explain how the Tenant’s rent or
assistance payment, if any, was computed.
25. Removal of Subsidy:
(a) The Tenant understands that assistance made available on his/her behalf may be
terminated if events in either item 1 or 2 below occur. Termination of assistance means that the
Landlord may make the assistance available to another Tenant and the Tenant’s rent will be
recomputed. In addition, if the Tenant’s assistance is terminated because of criterion (1) below,
the Tenant will be required to pay the HUD-approved market rent for the unit.
(1) The Tenant does not provide the Landlord with the information or reports required by
paragraph 15 or 16 within 10 calendar days after receipt of the Landlord’s notice of intent to
terminate the Tenant’s assistance payment.
(2) The amount the Tenant would be required to pay towards rent and utilities under HUD
rules and regulations equals the Family Gross Rent shown on Attachment 1.
(b) The Landlord agrees to give the Tenant written notice of the proposed termination. The
notice will advise the Tenant that, during the ten calendar days following the date of the notice,
he/she may request to meet with the Landlord to discuss the proposed termination of assistance.
If the Tenant requests a discussion of the proposed termination, the Landlord agrees to meet with
the Tenant.
(c) Termination of assistance shall not affect the Tenant’s other rights under this Agreement,
including the right to occupy the unit. Assistance may subsequently be reinstated if the Tenant

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Page 8 of 9

4350.3 REV-1

Appendix 4-B

______________________________________________________________________________________
submits the income or other data required by HUD procedures, the Landlord determines the
Tenant is eligible for assistance, and assistance is available.
26. Failure of the LANDLORD to insist upon the strict performance of the terms, covenants,
agreements and conditions herein contained, or any of them, shall not constitute or be construed
as a waver or relinquishment of the LANDLORD's right thereafter to enforce any such term,
covenant, agreement, or condition, but the same shall continue in full force and
effect.
27. In return for the TENANT's continued fulfillment of the terms and conditions of this
Agreement, the LANDLORD covenants that the TENANT may at all times, while this Agreement
remains in effect, have and enjoy for his/her sole use and benefit the above described property.
28. The lease agreement will terminate automatically, if the Section
8 Housing Assistance contract terminates for any reason.
29. Attachments to the Agreement: The Tenant certifies that he/she has received a copy of
the Agreement and the following attachments to the Agreement and understands that these
attachments are part of the Agreement.
a. Attachment No. 1 – Certification and Recertification of Tenant Eligibility. (59
Certification)
b. Attachment No. 2 – Unit Inspection Report.
c.

Attachment No. 3 – House Rules (if any).

d. Attachment No. 4 – Pet Rules.

WITNESS:
_____________________________________LANDLORD
_________________________
Date

By:__________________________________________

_________________________
Date

_______________________________________TENANT

_________________________
Date

_____________________________________________

_________________________
Date

_____________________________________________

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Appendix 4-C
Model Lease for Section 202 PRACs

4350.3 REV-1

Appendix 4-C

______________________________________________________________________________________

202 PRAC LEASE
Supportive Housing for the Elderly
This agreement made and entered into this ___________ day of
____________________________, 20___, between
________________________________________________________, as LANDLORD,
and
_______________________________________________________________, as
TENANT.
WITNESSETH:
WHEREAS, the LANDLORD is the Mortgagor under a Mortgage covering the
project in which the hereinafter described unit is situated, which
secures a capital advance made by the Secretary of Housing and Urban
Development (HUD) (hereinafter "Secretary") pursuant to Section 202 of
the Housing Act of 1959, as amended, and
WHEREAS, the LANDLORD has entered into a Project Rental Assistance
Contract (PRAC) with the Secretary.
WHEREAS, pursuant to a Regulatory Agreement entered into between the
LANDLORD and the Secretary, the LANDLORD has agreed to limit occupancy
of the project to elderly families and individuals as defined in Section
202 of the Housing Act of 1959, as amended, and applicable HUD
regulations under criteria for eligibility of TENANTS for admission to
assisted units and conditions of continued occupancy in accordance with
the terms and provisions of the PRAC Contract, and
NOW THEREFORE,
1.
The LANDLORD leases to the TENANT, and the TENANT leases from
the LANDLORD dwelling unit in the project known as ____________________
for a term of one year, commencing on the _____ day of _______________,
20__, and ending on the _____ day of ________________, 20__.
2.
The total rent (Contract Rent) shall be $_____________________
per month.
3.
The total rent specified in Paragraph 2, above, shall include
the following utilities:
____________________________________

________________________

____________________________________

________________________

(If the total rent includes all utilities, enter "ALL"; where
TENANTS pay some or all utilities, enter the following additional
paragraph as 3a.)

Page 1 of 10

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Appendix 4-C

4350.3 REV-1

______________________________________________________________________________________
The total rent stipulated herein does not include the cost of the
following utility service(s), for which the Utility allowance is
$________.
___________________________

__________________________________

___________________________

__________________________________

Charges for such service(s) is/are to be paid directly by the TENANT to
the utility company/companies providing such service(s). If the Utility
Allowance exceeds the required TENANT's share of the total housing
expense per HUD-approved schedule and criteria, the LANDLORD shall pay
the TENANT the amount of such excess on behalf of the Government upon
receipt of funds from HUD for that purpose.
4.
Of the total rent, $______________ shall be payable by or at
the direction of HUD as project rental assistance payments on behalf of
the TENANT, and $_______________________ shall be payable by the TENANT.
These amounts shall be subject to change by reason of changes in HUD’s
requirements, changes in the TENANT's family income, family composition,
or extent of exceptional medical or other unusual expenses in accordance
with HUD-established schedules and criteria; or by reason of adjustment
by HUD of any applicable Utility Allowance. Any such change shall be
effective as of the date stated in a Notice to the TENANT.
5.
The TENANT"S share of the rent shall be due and payable on or
before the first day of each month at _________________________ to the
LANDLORD, or to such other person or persons or at such places as the
LANDLORD may from time to time designate in writing.
6.
A security deposit in an amount equal to one month's total
tenant payment or $50, whichever is greater, shall be required at the
time of execution of this Agreement. Accordingly, TENANT hereby makes a
deposit of $____________________ against any damage except reasonable
wear done to the premises by the TENANT, his/her family, guests, or
agents, and agrees to pay when billed the full amount of any such damage
in order that the deposit will remain intact. Upon termination of this
Lease, the deposit is to be refunded to the TENANT or to be applied to
any such damage or any rent delinquency. The LANDLORD shall comply with
all State and local laws regarding interest payments on security
deposits.
7. The LANDLORD shall not discriminate against the TENANT in the
provision of services or in any other manner on the grounds of race,
color, creed, religion, sex, familial status, national origin, or
disability.
8. Unless terminated or modified as provided herein, this
Agreement shall be automatically renewed for successive terms of one
month each at the aforesaid rental, subject to adjustment as herein
provided.
(a) The TENANT may terminate this Agreement at the end of the
initial term or any successive term by giving 30 days written notice in
advance to the LANDLORD. Whenever the LANDLORD has been in material
noncompliance with this Agreement, the TENANT may in accordance with

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Page 2 of 10

4350.3 REV-1

Appendix 4-C

______________________________________________________________________________________
State law terminate this Agreement by so advising the LANDLORD in
writing.
(b) The LANDLORD's right to terminate this Agreement is
governed by the regulation of the Secretary at 24 CFR 891.430 and 24 CFR
Part 247 (herein referred to as the HUD Regulation). The HUD Regulation
provides that the LANDLORD may terminate this Agreement only under the
following circumstances:
(1) The LANDLORD may terminate, effective at the end of
the initial term or any successive term, by giving the TENANT
notification in the manner prescribed in paragraph (a) below that the
term of this Agreement is not renewed and this Agreement is accordingly
terminated. This termination must be based upon either material
noncompliance with this Agreement, material failure to carry out
obligations under any State landlord or tenant act, or criminal activity
that threatens the health, safety, or right to peaceful enjoyment of
their residences by persons residing in the immediate vicinity of the
premises-, any criminal activity that threatens the health or safety of
any on-site property management staff responsible for managing the
premises; or any drug-related criminal activity on or near such
premises, engaged in by a resident, any member of the resident's
household or other person under the resident's control; or other good
cause. When the termination of the tenancy is based on other good
cause, the termination notice shall so state, and the tenancy shall
terminate at the end of a term and in accordance with the termination
provisions of this Agreement, but in no case earlier than 30 days after
receipt by the TENANT of the notice. Where the termination notice is
based on material noncompliance with this Agreement or material failure
to carry out obligations under a State landlord and tenant act, the time
of service shall be in accordance with the previous sentence or State
law, whichever is later.
(2) Notwithstanding subparagraph (1), whenever the
TENANT has been in material noncompliance with this Agreement, the
LANDLORD may, in accordance with State law and the HUD Regulation,
terminate this Agreement by notifying the TENANT in the manner
prescribed in paragraph (g) below.
(c) If the TENANT does not vacate the premises on the
effective date of the termination of this Agreement, the LANDLORD may
pursue all judicial remedies under State or local law for the eviction
of the TENANT, and in accordance with the requirements in the HUD
Regulation.
(d) The term "material noncompliance with this Agreement"
shall, in the case of the TENANT, include (1) one or more substantial
violations of this Agreement, (2) repeated minor violations of this
Agreement which disrupt the livability of the project, adversely affect
the health or safety of any person or the right of any tenant to the
quiet enjoyment of the leased premises and related project facilities,
interfere with the management of the project or have an adverse
financial effect on the project, (3) failure of the TENANT to timely
supply all required information on the income and composition, or
eligibility factors of the TENANT household (including failure to meet
the disclosure and verification requirements for Social Security
Numbers, as provided by 24 CFR Part 5, or knowingly providing incomplete

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Appendix 4-C

4350.3 REV-1

______________________________________________________________________________________
or inaccurate information). Nonpayment of rent or any other financial
obligation due under this Agreement (including any portion thereof)
beyond any grace period permitted under State law shall constitute a
substantial violation. The payment of rent or any other financial
obligation due under this Agreement after the due date but within any
grace period permitted under State law shall constitute a minor
violation.
(e) The conduct of the TENANT cannot be deemed other good
cause unless the LANDLORD has given the TENANT prior notice that said
conduct shall henceforth constitute a basis for termination of this
Agreement. Said notice shall be served on the TENANT in the manner
prescribed in paragraph (g) below.
(f) The LANDLORD's determination to terminate this Agreement
shall be in writing and shall (1) state that the Agreement is terminated
on a date specified therein, (2) state the reasons for the LANDLORD's
action with enough specificity so as to enable the TENANT to prepare a
defense, (3) advise the TENANT that if he or she remains in the leased
unit on the date specified for termination, the LANDLORD may seek to
enforce the termination only by bringing a judicial action at which time
the TENANT may present a defense, and (4) be served on the TENANT in the
manner prescribed by paragraph (g) below.
(g) The LANDLORD's termination notice shall be accomplished
by (1) sending a letter by first class mail, properly stamped and
addressed, to the TENANT at his/her address at the project, with a
proper return address, and (2) serving a copy of said notice on any
adult person answering the door at the leased dwelling unit, or if no
adult responds, by placing the notice under or through the door, if
possible, or else by affixing the notice to the door. Service shall not
be deemed effective until both notices provided for herein have been
accomplished. The date on which the notice shall be deemed to be
received by the TENANT shall be the date on which the first class letter
provided for in clause (1)herein is mailed, or the date on which the
notice provided for in clause (2) is properly given, whichever is later.
(h) The LANDLORD may, with the prior approval of HUD, modify
the terms and conditions of the Agreement, effective at the end of the
initial term or a successive term, by serving an appropriate notice on
the TENANT, together with the tender of a revised Agreement or an
addendum revising the existing Agreement. Any increase in rent shall in
all cases be governed by 24 CFR Part 245, and other applicable HUD
regulations. This notice and tender shall be served on the TENANT (as
defined in paragraph (g)) at least 30 days prior to the last date on
which the TENANT has the right to terminate the tenancy without being
bound by the codified terms and conditions. The TENANT may accept it by
executing the tendered revised Agreement or addendum, or may reject it
by giving the LANDLORD written notice at least 30 days prior to its
effective date that he/she intends to terminate the tenancy. The
TENANT's termination notice shall be accomplished by sending a letter by
first class mail, properly stamped and addressed to the LANDLORD at
his/her address.
(i) The LANDLORD may terminate this Agreement for the
following reasons:

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Page 4 of 10

4350.3 REV-1

Appendix 4-C

______________________________________________________________________________________
1. drug related criminal activity engaged in on or near
the premises, by any TENANT, household member, or guest, and any such
activity engaged in on the premises by any other person under the
tenant’s control;
2. determination made by the LANDLORD that a household
member is illegally using a drug;
3. determination made by the LANDLORD that a pattern of
illegal use of a drug interferes with the health, safety, or right to
peaceful enjoyment of the premises by other residents;
4. criminal activity by a tenant, any member of the
TENANT’S household, a guest or another person under the TENANT’S
control:
(a) that threatens the health, safety, or right to
peaceful enjoyment of the premises by other residents (including
property management staff residing on the premises); or
(b) that threatens the health, safety, or right to
peaceful enjoyment of their residences by persons residing in the
immediate vicinity of the premises;
5. if the TENANT is fleeing to avoid prosecution, or
custody or confinement after conviction, for a crime, or attempt to
commit a crime, that is a felony under the laws of the place from which
the individual flees, or that in the case of the State of New Jersey, is
a high misdemeanor; or
6. if the TENANT is violating a condition of probation or
parole under Federal or State law;
7. determination made by the LANDLORD that a household
member’s abuse or pattern of abuse of alcohol threatens the health,
safety, or right to peaceful enjoyment of the premises by other
residents;
8. if the LANDLORD determines that the tenant, any member
of the TENANT’S household, a guest or another person under the TENANT’S
control has engaged in criminal activity, regardless of whether the
tenant, any member of the tenant’s household, a guest or another person
under the tenant’s control has been arrested or convicted for such
activity.
9.
TENANT agrees that the family income, family composition and
other eligibility requirements shall be deemed substantial and material
obligations of his/her tenancy with respect to the amount of rental
he/she will be obligated to pay and his/her right of occupancy, and that
a recertification of income shall be made to the LANDLORD annually from
the date of this lease in accordance with HUD regulations and
requirements.
10. TENANT agrees that the TENANT's share of the monthly rental
payment is subject to adjustment by the LANDLORD to reflect income
changes which are disclosed on any of TENANT's recertification of
income, and TENANT agrees to be bound by such adjustment. LANDLORD

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Appendix 4-C

4350.3 REV-1

______________________________________________________________________________________
agrees to give 30 days written notice of any such adjustment to the
TENANT, by an addendum to be made a part of this lease, stating the
amount of the adjusted monthly rental which the TENANT will be required
to pay.
11. The TENANT shall not assign this lease, sublet the premises,
give accommodation to any roomers or lodgers, or permit the use of the
premises for any purpose other than as a private dwelling solely for the
TENANT and his/her family. The TENANT agrees to reside in this unit and
agrees that this unit shall be the TENANT's and his/her family's only
place of residence.
12. TENANT agrees to pay the LANDLORD any rental which should have
been paid but for (a) TENANT's misrepresentation in his/her initial
income certification or recertification, or in any other information
furnished to the LANDLORD or (b) TENANT's failure to supply income
recertification when required or to supply information requested by the
LANDLORD.
13. TENANT for himself/herself and his/her heirs, executors and
administrators agrees as follows:
(a) To pay the rent herein stated promptly when due, without
any deductions whatsoever, and without any obligation on the part of the
LANDLORD to make any demand for the same;
(b) To keep the premises in a clean and sanitary condition,
and to comply with all obligations imposed upon TENANT under applicable
provisions of building and housing codes materially affecting health and
safety with respect to said premises and appurtenances, and to save the
LANDLORD harmless from all fines, penalties and costs for violations or
noncompliance by TENANT with any of said laws, requirements or
regulations, and from all liability arising out of any such violations
or noncompliance.
(c) Not to use premises for any purpose deemed hazardous by
insurance companies carrying insurance thereon;
(d) That if any damage to the property shall be caused by
his/her acts or neglect, the TENANT shall forthwith repair such damage
at his/her own expense, and should the TENANT fall or refuse to make
such repairs within a reasonable time after the occurrence of such
damage, the LANDLORD may, at his/her option, make such repairs and
charge the cost thereof to the TENANT, and the TENANT shall thereupon
reimburse the LANDLORD for the total cost of the damages so caused;
(e) To permit the LANDLORD, or his/her agents, or any
representative of any holder of a mortgage on the property, or when
authorized by the LANDLORD, the employees of any contractor, utility
company, municipal agency or others, to enter the premises for the
purpose of making reasonable inspections and repairs and replacements"
(f)

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Not to install a washing machine, clothes dryer, or air
conditioning unit in the apartment without the prior
approval of the LANDLORD, and

Page 6 of 10

4350.3 REV-1

Appendix 4-C

______________________________________________________________________________________
(g) To permit the LANDLORD or his/her agents to bring
appropriate legal action in the event of a breach or threatened breach
by the TENANT of any of the covenants or provisions of this lease.
14. The TENANT is permitted to keep common household pets in
his/her dwelling unit(subject to the provisions in 24 CFR Part 5 Subpart
C) and the pet rules promulgated under 24 CFR 5.315). Any pet rules
promulgated by the LANDLORD are attached hereto and incorporated hereby.
The TENANT agrees to comply with these rules. A violation of these
rules may be grounds for removal of the pet or termination of the
TENANT's (pet owner's) tenancy (or both), in accordance with the
provisions of 24 CFR Part 5, Subpart C and applicable regulations and
State or local law. These regulations include 24 CFR Part 247
(Evictions From Certain Subsidized and HUD-Owned Projects) and
provisions governing the termination of tenancy under the Project Rental
Assistance Contract.
Note:
The Part 5 Pet Rules do not apply to an animal used by a Tenant
or visitor that is needed as a reasonable accommodation for the Tenant’s
or visitor’s disability.
[Optional] The LANDLORD may after reasonable notice to the TENANT and
during reasonable hours, enter and inspect the premises. Entry and
inspection is permitted only if the LANDLORD has received a signed,
written complaint alleging (or the LANDLORD has reasonable grounds to
believe) that the conduct or condition of a pet in the dwelling unit
constitutes, under applicable State or local law, a nuisance or a threat
to the health or safety of the occupants of the project or other persons
in the community where the project is located.
If there is not State or local authority (or designated agent of
such an authority) authorized under applicable State or local law to
remove a pet that becomes vicious, displays symptoms of severe illness,
or demonstrates other behavior that constitutes an immediate threat to
the health or safety of the tenancy as a whole, the LANDLORD may enter
the premises (if necessary), remove the pet, and take such action with
respect to the pet as may be permissible under State and local law,
which may include placing it in a facility that will provide care and
shelter for a period not to exceed 30 days. The LANDLORD shall enter
the premises and remove the pet or take such other permissible action
only if the LANDLORD requests the TENANT (pet owner) to remove the pet
from the project immediately, and the TENANT (pet owner) refuses to do
so, or if the LANDLORD is unable to contact the TENANT (pet owner) to
make a removal request. The cost of the animal care facility shall be
paid as provided in 24 CFR 5.363.
15. The LANDLORD agrees to comply with the requirement of all
applicable Federal, State, and local laws, including health, housing and
building codes and to deliver and maintain the premises in safe,
sanitary decent condition.
16. The TENANT, by the execution of this Agreement, admits that
the dwelling unit described herein has been inspected by him/her and
meets with his/her approval. The TENANT acknowledges hereby that said
premises have been satisfactorily completed and that the LANDLORD will
not be required to repaint, replaster, or otherwise perform any other
work, labor, or service which it has already performed for the TENANT.

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Appendix 4-C

4350.3 REV-1

______________________________________________________________________________________
The TENANT admits that he/she has inspected the unit and found it to be
in good and tenantable condition, and agrees that at the end of the
occupancy hereunder to deliver up and surrender said premises to the
LANDLORD in as good condition as when received, reasonable wear and tear
excepted.
17. No alteration, addition, or improvements shall be made in or
to the premises without the prior consent of the LANDLORD in writing.
The LANDORD agrees to provide reasonable accommodation to an otherwise
eligible tenant’s disability, including making changes to rules,
policies, or procedures, and making and paying for structural
alterations to a unit or common areas. The Landlord is not required to
provide accommodations that constitute a fundamental alteration to the
Landlord’s program or which would pose a substantial financial and
administrative hardship. See the regulations at 24 CFR Part 8. In
addition, if a requested structural modification does pose a substantial
financial and administrative hardship, the Landlord must then allow the
tenant to make and pay for the modification in accordance with the Fair
Housing Act.
18. TENANT agrees not to waste utilities furnished by the LANDLORD;
not to use utilities or equipment for any improper or unauthorized
purpose; and not to place fixtures, signs, or fences in or about the
premises without the prior permission of the LANDLORD in writing. If
such permission is obtained, TENANT agrees, upon termination of the
lease, to remove any fixtures, signs of fences, at the option of the
LANDLORD, without damage to the premises.
19. This Agreement shall be subordinate in respect to any
mortgages that are now on or that hereafter may be placed against said
premises, and the recording of such mortgage or mortgages shall have
preference and precedence and be superior and prior in lien to this
Agreement, and the TENANT agrees to execute any such instrument without
cost, which may be deemed necessary or desirable to further effect the
subordination of this Agreement to any such mortgage or mortgages and a
refusal to execute such instruments shall entitle the LANDLORD, or the
LANDLORD's assigns and legal representatives to the option of canceling
this Agreement without incurring any expense or damage, and the term
hereby granted is expressly limited accordingly.
20. Failure of the LANDLORD to insist upon the strict performance
of the terms, covenants, agreements and conditions herein contained, or
any of them, shall not constitute or be construed as a waiver or
relinquishment of the LANDLORD's right thereafter to enforce any such
term, covenant, agreement, or condition, but the same shall continue in
full force and effect.
21. In return for the TENANT's continued fulfillment of the terms
and conditions of this Agreement, the LANDLORD covenants that the TENANT
may at all times, while this Agreement remains in effect, have and enjoy
for his/her sole use and benefit the above described property.
22. Tenant Income Verification: The TENANT must promptly provide
the LANDLORD with any letter or other notice by HUD to a member of the
family that provides information concerning the amount or verification
of family income in accordance with HUD requirements.

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4350.3 REV-1

Appendix 4-C

______________________________________________________________________________________
23. Tenants’ rights to organize: LANDLORD agrees to allow TENANT
organizers to conduct on the property the activities related to the
establishment or operation of a TENANT organization set out in
accordance with HUD requirements.
24.

Interim recertifications:
a. The TENANT agrees to advise the LANDLORD immediately if
any of the following changes occur:
1.

Any household member moves out of the unit.

2. Any adult member of the household who was reported
as unemployed on the most recent certification or
recertification obtains employment.
3. The household’s income cumulatively increases by
$200 or more a month.
b. The TENANT may report any decrease in income or any
change in other factors considered in calculating the Tenant’s rent.
Unless the LANDLORD has confirmation that the decrease in income or
change in other factors will last less than one month, the LANDLORD will
verify the information and make the appropriate rent reduction.
However, if the TENANT’S income will be partially or fully restored
within two months, the LANDLORD may delay the certification process
until the new income is known, but the rent reduction will be
retroactive and LANDLORD may not evict the TENANT for nonpayment of rent
due during the period of the reported decrease and the completion of the
certification process. The TENANT has thirty days after receiving
written notice of any rent due for the above described time period to
pay or the LANDLORD can evict for nonpayment of rent.
c. If the TENANT does not advise the LANDLORD of the interim
changes concerning household members or increase in income, the TENANT
may be subject to eviction. The LANDLORD may evict TENANT only in
accordance with the time frames and administrative procedures set forth
in HUD’s regulations, handbooks and instructions on the administration
of multifamily subsidy programs.
d. The TENANT may request to meet with the LANDLORD to
discuss how any change in income or other factors affected his/her rent
or assistance payment, if any. If the TENANT requests such a meeting,
the LANDLORD agrees to meet with the TENANT and explain how the
TENTANT’S rent or assistance payment, if any, was computed.
25. Attachments to the Agreement: The Tenant certifies that
he/she has received a copy of the Agreement and the following
attachments to the Agreement and understands that these attachments are
part of the Agreement.
a. Attachment No. 1 - Certification and Recertification of
Tenant Eligibility. (59 Certification)
b. Attachment No. 2 - Unit Inspection Report.
c. Attachment No. 3 - House Rules (if any).

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______________________________________________________________________________________
d. Attachment No. 4 – Pet Rules
WITNESS:
_________________
Date

____________________________________LANDLORD
By: ________________________________

_________________
Date

___________________________________TENANT

_________________

___________________________________

_________________

___________________________________

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Page 10 of 10

Appendix 4-D
Model Lease for Section 811 PRACs

Appendix 4-D

4350.3 REV-1

______________________________________________________________________________________
811 PRAC LEASE
SUPPORTIVE HOUSING FOR PERSONS WITH DISABILITIES
This agreement made and entered into this _____________ day of
______________________, 20___, between ___________________________
as LANDLORD, and ___________________________________as Tenant.
WITNESSETH:
WHEREAS, the LANDLORD is the Mortgagor under a Mortgage covering the
project in which the hereinafter described unit is situated, which
secures a capital advance made by the Secretary of Housing and Urban
Development (HUD) (hereinafter "Secretary") pursuant to Section 811 of
the National Affordable Housing Act, as amended by the Housing and
Community Development Act of 1992 and
WHEREAS, the LANDLORD has entered into a Project Rental Assistance
Contract (PRAC) with the Secretary.
WHEREAS, pursuant to a Regulatory Agreement entered into between the
LANDLORD and the Secretary, the LANDLORD has agreed to limit occupancy
of the project to persons with disabilities as defined in Section 811 of
the National Affordable Housing Act, as amended by the Housing and
Community Development Act of 1992 and applicable HUD regulations under
criteria for eligibility of TENANTS for admission to assisted units and
conditions of continued occupancy in accordance with the terms and
provisions of the PRAC Contract, and
NOW THEREFORE,
1.
The LANDLORD leases to the TENANT, and the TENANT leases from
the LANDLORD dwelling unit in the project known as
____________________________________ for a term of one year commencing
on the _____ day of ___________________________, 20__, and ending on the
_____ day of _____________________, 20__.
2.

The total rent (Contract Rent) shall be $__________ per month.

3.
The total rent specified in Paragraph 2, above, shall include
the following utilities:
________________________

____________________________

(If the total rent includes all utilities, enter "ALL"; where
TENANTS pay some or all utilities, enter the following additional
paragraph as 3a.)
The total rent stipulated herein does not include the cost of the
following utility service(s), for which the Utility Allowance is $____.
________________________
_____________________________
________________________

_____________________________

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4350.3 REV-1

Appendix 4-D

______________________________________________________________________________________
Charges for such service(s) are to be paid directly by the TENANT to the
utility company/companies providing such service(s). If the Utility
Allowance exceeds the required TENANT's share of the total housing
expense per HUD-approved schedule and criteria, the LANDLORD shall pay
the TENANT the amount of such excess on behalf of the Government upon
receipt of funds from HUD for that purpose.
4.
Of the total rent, $___________ shall be payable by or at the
direction of HUD as project rental assistance payments on behalf of the
TENANT, and $_______________ shall be payable by the TENANT. These
amounts shall be subject to change by reason of changes in requirements,
changes in the TENANT's family income, family composition or extent of
exceptional medical or other unusual expenses in accordance with HUDestablished schedules and criteria; or by reason of adjustment by HUD of
any applicable Utility Allowance. Any such change shall be effective as
of the date stated in a Notice to the TENANT.
5.
The TENANT's share of the rent shall be due and payable on or
before the first day of each month at ______________________________ to
the LANDLORD, or to such other person or persons or at such places as
the LANDLORD may from time to time designate in writing.
6.
A security deposit in an amount equal to one month's total
TENANT payment or $50, whichever is greater, shall be required at the
time of execution of this Agreement, Accordingly, TENANT hereby makes a
deposit of $__________________ against any damage except reasonable wear
done to the premises by the TENANT, his/her family, guests, or agents;
and agrees to pay when billed the full amount of any such damage in
order that the deposit will remain intact. Upon termination of this
Lease, the deposit is to be refunded to the TENANT or to be applied to
any such damage or any rent delinquency. The LANDLORD shall comply with
all State and local laws regarding interest payments on security
deposits.
7.
The LANDLORD shall not discriminate against the TENANT in the
provision of services or in any other manner on the grounds of race,
color, creed, religion, sex, familial status, national origin, or
disability.
8.
Unless terminated or modified as provided herein, this
Agreement shall be automatically renewed for successive terms of One
month each at the aforesaid rental, subject to adjustment as herein
provided.
(a) The TENANT may terminate this Agreement at the end of the
initial term or any successive term by giving 30 days written notice in
advance to the LANDLORD. Whenever the LANDLORD has been in material
noncompliance with this Agreement, the TENANT may in accordance with
State law terminate this Agreement by so advising the LANDLORD in
writing.
(b) The LANDLORD's right to terminate this Agreement is
governed by the regulation of the Secretary at 24 CFR 891.430 and Part
247 (herein referred to as the HUD Regulation). The HUD Regulation
provides that the LANDLORD may terminate this Agreement only under the
following circumstances:

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Page 2 of 10

Appendix 4-D

4350.3 REV-1

______________________________________________________________________________________
(1) The LANDLORD may terminate, effective at the end of
the initial term or any successive term, by giving the TENANT
notification in the manner prescribed in paragraph (g)below that the
term of this Agreement is not renewed and this Agreement is accordingly
terminated. This termination must be based upon either material
noncompliance with this Agreement, material failure to carry out
obligations under any State landlord or tenant act, or criminal activity
that threatens the health, safety, or right to peaceful enjoyment of
their residences by persons residing in the immediate vicinity of the
premises; any criminal activity that threatens the health or safety of
any on-site project management staff responsible for managing the
premises, or any drug-related criminal activity on or near such
premises, engaged in by a resident, any member of the resident's
household or other person under the resident's control; or other good
cause. When the termination of the tenancy is based on other good
cause, the termination notice shall so state, at the end of a term and
in accordance with the termination provisions of this Agreement, but in
no case earlier than 30 days after receipt by the TENANT of the notice.
Where the termination notice is based on material noncompliance with
this Agreement or material failure to carry out obligations under a
State landlord and tenant act, the time of service shall be in
accordance with the previous sentence or State law, whichever is later.
(2) Notwithstanding subparagraph (1), whenever the
TENANT has been in material noncompliance with this Agreement, the
LANDLORD may, in accordance with State law and the HUD Regulation,
terminate this Agreement by notifying the TENANT in the manner
prescribed in paragraph (g) below.
(c) If the TENANT does not vacate the premises on the
effective date of the termination of this Agreement, the LANDLORD may
pursue all judicial remedies under State or local law for the eviction
of the TENANT, and in accordance with the requirements in the HUD
Regulation.
(d) The term "material noncompliance with this Agreement"
shall, in the case of the TENANT, include (1) one or more substantial
violations of this Agreement, (2) repeated minor violations of this
Agreement which disrupt the livability of the project, adversely affect
the health or safety of any person or the right of any tenant to the
quiet enjoyment of the leased premises and related project facilities,
interfere with the management of the project or have an adverse
financial effect on the project, (3) failure of the TENANT to timely
supply all required information on the income and composition, or
eligibility factors of the TENANT household (including failure to meet
the disclosure and verification requirements for Social Security
Numbers, as provided by 24 CFR Part 5, Subpart B or knowingly providing
incomplete or inaccurate information). Nonpayment of rent or any other
financial obligation due under this Agreement (including any portion
thereof) beyond any grace period permitted under State law shall
constitute a substantial violation. The payment of rent or any other
financial obligation due under this Agreement after the due date but
within any grace period permitted under State law shall constitute a
minor violation.
(e) The conduct of the TENANT cannot be deemed other good
cause unless the LANDLORD has given the TENANT prior notice that said

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4350.3 REV-1

Appendix 4-D

______________________________________________________________________________________
conduct shall henceforth constitute a basis for termination of this
Agreement. Said notice shall be served on the TENANT in the manner
prescribed in paragraph (g) below.
(f) The LANDLORD's determination to terminate this Agreement
shall be in writing and shall (1) state that the Agreement is terminated
on a date specified therein, (2) state the reasons for the LANDLORD's
action with enough specificity so as to enable the TENANT to prepare a
defense, (3) advise the TENANT that is he or she remains in the leased
unit on the date specified for termination, the LANDLORD may seek to
enforce the termination only by bringing a judicial action at which time
the TENANT may present a defense, and (4) be served on the TENANT in the
manner prescribed by paragraph (g) below.
(g) The LANDLORD's termination notice shall be accomplished
by (1) sending a letter by first class mail, properly stamped and
addressed, to the TENANT at his/her address at the project, with a
proper return address, and (2) serving a copy of said notice on any
adult person answering the door at the leased dwelling unit, or if no
adult responds, by placing the notice under or through the door, if
possible, or else by affixing the notice to the door. Service shall not
be deemed effective until both notices provided for herein have been
accomplished. The date on which the notice shall be deemed to be
received by the TENANT shall be the date on which the first class letter
provided for in clause (1) herein is mailed, or the date on which the
notice provided for in clause (2) is properly given, whichever is later.
(h) The LANDLORD may, with the prior approval of HUD, modify
the terms and conditions of the Agreement, effective at the end of the
initial term or a successive term, by serving an appropriate notice on
the TENANT, together with the tender of a revised Agreement or an
addendum revising the existing Agreement. Any increase in rent shall, in
all cases, be governed by 24 CFR Part 245, and other applicable HUD
regulations. This notice and tender shall be served on the TENANT (as
defined in paragraph (g)) at least 30 days prior to the last date on
which the TENANT has the right to terminate the tenancy without being
bound by the codified terms and conditions. The TENANT may accept it by
executing the tendered revised agreement or addendum, or may reject it
by giving the LANDLORD written notice at least 30 days prior to its
effective date that he/she intends to terminate the tenancy. The
TENANT's termination notice shall be accomplished by sending a letter by
first class mail, properly stamped and addressed to the LANDLORD at
his/her address.
(i) The LANDLORD may terminate this Agreement for the
following reasons:
1. drug related criminal activity engaged in on or near
the premises, by any TENANT, household member, or guest, and any such
activity engaged in on the premises by any other person under the
tenant’s control;
2. determination made by the LANDLORD that a household
member is illegally using a drug;

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Appendix 4-D

4350.3 REV-1

______________________________________________________________________________________
3. determination made by the LANDLORD that a pattern of
illegal use of a drug interferes with the health, safety, or right to
peaceful enjoyment of the premises by other residents;
4. criminal activity by a tenant, any member of the
TENANT’S household, a guest or another person under the TENANT’S
control:
(a) that threatens the health, safety, or right to
peaceful enjoyment of the premises by other residents (including
property management staff residing on the premises); or
(b) that threatens the health, safety, or right to
peaceful enjoyment of their residences by persons residing in the
immediate vicinity of the premises;
5. if the TENANT is fleeing to avoid prosecution, or
custody or confinement after conviction, for a crime, or attempt to
commit a crime, that is a felony under the laws of the place from which
the individual flees, or that in the case of the State of New Jersey, is
a high misdemeanor; or
6. if the TENANT is violating a condition of probation
or parole under Federal or State law;
7. determination made by the LANDLORD that a household
member’s abuse or pattern of abuse of alcohol threatens the health,
safety, or right to peaceful enjoyment of the premises by other
residents;
8. if the LANDLORD determines that the tenant, any
member of the TENANT’S household, a guest or another person under the
TENANT’S control has engaged in criminal activity, regardless of whether
the tenant, any member of the tenant’s household, a guest or another
person under the tenant’s control has been arrested or convicted for
such activity.
9.
TENANT agrees that the family income, family composition and
other eligibility requirements shall be deemed substantial and material
obligations of his/her tenancy with respect to the amount of rental
he/she will be obligated to pay and his/her right of occupancy, and that
a recertification of income shall be made to the LANDLORD annually from
the date of this lease in accordance with HUD regulations and
requirements.
10. TENANT agrees that the TENANT's share of the monthly rental
payment is subject to adjustment by the LANDLORD to reflect income
changes which are disclosed on any of TENANT's recertification of
income, and TENANT agrees to be bound by such adjustment. LANDLORD
agrees to give 30 days written notice of any such adjustment to the
TENANT, by an addendum to be made a part of this lease, stating the
amount of the adjusted monthly rental which the TENANT will be required
to pay.
11. The TENANT shall not assign this lease, sublet the premises,
give accommodation to any roomers or-lodgers, or permit the use of the
premises for any purpose other than as a private dwelling solely for the

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Appendix 4-D

______________________________________________________________________________________
TENANT and his/her family. The TENANT agrees to reside in this unit and
agrees that this unit shall be the TENANT's and his/her family's only
place of residence.
12. TENANT agrees to pay the LANDLORD any rental which should have
been paid but for (a) TENANT's misrepresentation in his/her initial
income certification or recertification, or in any other information
furnished to the LANDLORD or (b) TENANT's failure to supply income
recertification when required or to supply information requested by the
LANDLORD.
13. TENANT for himself/herself and his/her heirs, executors and
administrators agrees as follows:
(a) To pay the rent herein stated promptly when due, without
any deductions whatsoever, and without any obligation on the part of the
LANDLORD to make any demand for the same;
(b) To keep the premises in a clean and sanitary condition,
and to comply with all obligations imposed upon TENANTS under applicable
provisions of building and housing codes materially affecting health and
safety with respect to said premises and appurtenances, and to save the
LANDLORD harmless from all fines, penalties and costs for violations or
noncompliance by TENANT with any of said laws, requirements or
regulations, and from all liability arising out of any such violations
or noncompliance.
(c) Not to use premises for any purpose deemed hazardous by
insurance companies carrying insurance thereon;
(d) That if any damage to the property shall be caused by
his/her acts or neglect, the TENANT shall forthwith repair such damage
at his/her own expense, and should the TENANT fall or refuse to make
such repairs within a reasonable time after the occurrence of such
damage, the LANDLORD may, at his/her option, make such repairs and
charge the cost thereof to the TENANT, and the TENANT shall thereupon
reimburse the LANDLORD for the total cost of the damages so caused,
(e) To permit the LANDLORD, or his/her agents, or any
representative of any holder of a mortgage on the property, or when
authorized by the LANDLORD, the employees of any contractor, utility
company, municipal agency or others, to enter the premises for the
purpose of making reasonable inspections and repairs and replacements,
(f) Not to install a washing machine, clothes dryer, or air
conditioning unit in the apartment without the prior approval of the
LANDLORD; and
(g)

To permit the LANDLORD or his/her agents to bring
appropriate legal action in the event of a breach or
threatened breach by the TENANT of any of the covenants
or provisions of this lease.

14. The TENANT is permitted to keep common household pets in
his/her dwelling unit or in an independent living facility (subject to
the provisions in 24 CFR Part 5, Subpart C) and the et rules promulgated
under 24 CFR 5.315). Project owners may limit the number of common

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Appendix 4-D

4350.3 REV-1

______________________________________________________________________________________
household pets to one pet in each group home. (24 CFR 5.318(b)(ii)). Any
pet rules promulgated by the LANDLORD are attached hereto and
incorporated hereby. The TENANT agrees to comply with these rules. A
violation of these rules may be grounds for removal of the pet or
termination of the TENANT's (pet owner's) tenancy (or both), in
accordance with the provisions of 24 CFR Part 5, Subpart C, and
applicable regulations and State or local law. These regulations
include 24 CFR Part 247 (Evictions From Certain Subsidized and HUD-Owned
Projects) and provisions governing the termination of tenancy under the
Project Rental Assistance Contract.
Note:
The Part 5 Pet Rules do not apply to an animal used by a Tenant
or visitor that is needed as a reasonable accommodation for the Tenant’s
or visitor’s disability.
[Optional] The LANDLORD may after reasonable notice to the TENANT and
during reasonable hours, enter and inspect the premises. Entry and
inspection is permitted only if the LANDLORD has received a signed,
written complaint alleging (or the LANDLORD has reasonable grounds to
believe) that the conduct or condition of a pet in the dwelling unit
constitutes, under applicable State or local law, a nuisance or a threat
to the health or safety of the occupants of the project or other persons
in the community where the project is located.
If there is not State or local authority (or designated agent of
such an authority) authorized under applicable State or local law to
remove a pet that becomes vicious, displays symptoms of severe illness,
or demonstrates other behavior that constitutes an immediate threat to
the health or safety of the tenancy as a whole, the LANDLORD may enter
the premises (if necessary), remove the pet, and take such action with
respect to the pet as may be permissible under State and local law,
which may include placing it in a facility that will provide care and
shelter for a period not to exceed 30 days. The LANDLORD shall enter
the premises and remove the pet or take such other permissible action
only if the LANDLORD requests the TENANT (pet owner) to remove the pet
from the project immediately, and the TENANT (pet owner) refuses to do
so, or if the LANDLORD is unable to contact the TENANT (pet owner) to
make a removal request. The cost of the animal care facility shall be
paid as provided in 24 CFR 5.363. (NOTE:
Paragraph 14 does not apply
to individual residents of 811 Group Homes.
15. The LANDLORD agrees to comply with the requirement of all
applicable Federal, State, and local laws, including health, housing and
building codes and to deliver and maintain the premises in safe,
sanitary decent condition.
16. The TENANT, by the execution of this Agreement, admits that
the dwelling unit described herein has been inspected by him/her and
meets with his/her approval. The TENANT acknowledges hereby that said
premises have been satisfactorily completed and that the LANDLORD will
not be required to repaint, replaster, or otherwise perform any other
work, labor, or service which it has already performed for the TENANT.
The TENANT admits that he/she has inspected the unit and found it to be
in good and tenantable condition, and agrees that at the end of the
occupancy hereunder to deliver up and surrender said premises to the
LANDLORD in as good condition as when received, reasonable wear and tear
excepted.

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Appendix 4-D

______________________________________________________________________________________
17. No alteration, addition, or improvements shall be made in or
to the premises without the prior consent of the LANDLORD in writing.
The LANDORD agrees to provide reasonable accommodation to an otherwise
eligible tenant’s disability, including making changes to rules,
policies, or procedures, and making and paying for structural
alterations to a unit or common areas. The Landlord is not required to
provide accommodations that constitute a fundamental alteration to the
Landlord’s program or which would pose a substantial financial and
administrative hardship. See the regulations at 24 CFR Part 8. In
addition, if a requested structural modification does pose a substantial
financial and administrative hardship, the Landlord must then allow the
tenant to make and pay for the modification in accordance with the Fair
Housing Act.
18. TENANT agrees not to waste utilities furnished by the
LANDLORD; not to use utilities or equipment for any improper or
unauthorized purpose, and not to place fixtures, signs, or fences in or
about the premises without the prior permission of the LANDLORD in
writing. If such permission is obtained, TENANT agrees, upon
termination of the lease, to remove any fixtures, signs of fences, at
the option of the LANDLORD, without damage to the premises.
19. This Agreement shall be subordinate in respect to any
mortgages that are now on or that hereafter may be placed against said
premises, and the recording of such mortgage or mortgages shall have
preference and precedence and be superior and prior in lien to this
Agreement, and the TENANT agrees to execute any such instrument without
cost, which may be deemed necessary or desirable to further effect the
subordination of this Agreement to any such mortgage or mortgages and a
refusal to execute such instruments shall entitle the LANDLORD, or the
LANDLORD's assigns and legal representatives to the option of canceling
this Agreement without incurring any expense or damage, and the term
hereby granted is expressly limited accordingly.
20. Failure of the LANDLORD to insist upon the strict performance
of the terms, covenants, agreements and conditions herein contained, or
any of them, shall not constitute or be construed as a waiver or
relinquishment of the LANDLORD's right thereafter to enforce any such
term, covenant, agreement, or condition, but the same shall continue in
full force and effect.
21. In return for the TENANT's continued fulfillment of the terms
and conditions of this Agreement, the LANDLORD covenants that the TENANT
may at all times, while this Agreement remains in effect, have and enjoy
for his/her sole use and benefit the above described property.
22. Tenant Income Verification: The TENANT must promptly provide
the LANDLORD with any letter or other notice by HUD to a member of the
family that provides information concerning the amount or verification
of family income in accordance with HUD requirements.
23. Tenants’ rights to organize: LANDLORD agrees to allow TENANT
organizers to conduct on the property the activities related to the
establishment or operation of a TENANT organization set out in
accordance with HUD requirements.

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Page 8 of 10

Appendix 4-D

4350.3 REV-1

______________________________________________________________________________________
24. Interim recertifications:
a. The TENANT agrees to advise the LANDLORD immediately
if any of the following changes occur.
1.

Any household member moves out of the unit.

2. Any adult member of the household who was reported
as unemployed on the most recent certification or
recertification obtains employment.
3. The household’s income cumulatively increases by
$200 or more a month.
b. The TENANT may report any decrease in income or any change
in other factors considered in calculating the Tenant’s rent. Unless
the LANDLORD has confirmation that the decrease in income or change in
other factors will last less than one month, the LANDLORD will verify
the information and make the appropriate rent reduction. However, if
the TENANT’S income will be partially or fully restored within two
months, the LANDLORD may delay the certification process until the new
income is known, but the rent reduction will be retroactive and LANDLORD
may not evict the TENANT for nonpayment of rent due during the period of
the reported decrease and the completion of the certification process.
The TENANT has thirty days after receiving written notice of any rent
due for the above described time period to pay or the LANDLORD can evict
for nonpayment of rent.
c. If the TENANT does not advise the LANDLORD of the interim
changes concerning household members or increase in income, the TENANT
may be subject to eviction. The LANDLORD may evict TENANT only in
accordance with the time frames and administrative procedures set forth
in HUD’s regulations, handbooks and instructions on the administration
of multifamily subsidy programs.
d. The TENANT may request to meet with the LANDLORD to
discuss how any change in income or other factors affected his/her rent
or assistance payment, if any. If the TENANT requests such a meeting,
the LANDLORD agrees to meet with the TENANT and explain how the
TENTANT’S rent or assistance payment, if any, was computed.
25.
Attachments to the Agreement: The Tenant certifies that
he/she has received a copy of the Agreement and the following
attachments to the Agreement and understands that these attachments are
part of the Agreement.
a. Attachment No. 1 - Certification and Recertification of
Tenant Eligibility. (59 Certification)
b. Attachment No. 2 - Unit Inspection Report.
c. Attachment No. 3 - House Rules (if any).
d. Attachment No. 4 – Pet Rules

Page 9 of 10

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4350.3 REV-1

Appendix 4-D

______________________________________________________________________________________

WITNESS:
_______________
Date

______________________________LANDLORD
By: __________________________

_______________
Date

______________________________TENANT

_______________

______________________________

_______________

______________________________

5/03

Page 10 of 10

Appendix 5
Sample Move-In/Move-Out Inspection
Format

Appendix 5

4350.3 REV-1

Appendix 5: Move-In/Move-Out Inspection Format
[Company name]
[Company address]
Property
Apartment No.

Item

Resident
Unit Size

Move-In Inspection Date

Cost to Correct

Condition
Move-In

Move-Out Inspection Date

Move-Out

ENTRANCE/HALLS
Steps and landings
Handrails
Doors
Hardware/Locks
Floors/Coverings
Walls/Coverings
Ceilings
Windows/Coverings
Lighting1
Electrical Outlets
Closets2
Fire alarms/equipment

LIVING ROOM
Floor/Coverings
Walls/Coverings
Ceiling
Windows/Covering
Lighting1
Electrical outlets

HUD Occupancy Handbook
Appendix 5: Move-In/Move-Out Inspection Format

1

5/03

4350.3 REV-1

Appendix 5

Item

Condition
Move-In

Cost to Correct
Move-Out

DINING ROOM
Floor/Coverings
Walls/Coverings
Ceiling
Windows/Coverings
Lighting1
Electrical outlets

KITCHEN
Range
Refrigerator
Sink/Faucets3
Floor/Coverings
Walls/Coverings
Ceiling
Windows/Coverings
Lighting1
Electrical outlets
Cabinets
Closets/Pantry2
Exhaust fan
Fire alarms/equipment

BEDROOM(S)
Doors and locks
Floor/Coverings
Walls/Coverings
Ceiling
Windows/Covering
Closets2
Lighting1
Electrical outlets

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HUD Occupancy Handbook
Appendix 5: Move-In/Move-Out Inspection Format

Appendix 5

Item

4350.3 REV-1

Cost to Correct

Condition
Move-In

Move-Out

BATHROOM(S)
Sink/Faucets3
Shower/Tub3
Curtain rack/Door
Towel rack
Toilet
Doors/Locks
Floor/Coverings
Walls/Coverings
Ceiling
Windows/Coverings
Closets2
Cabinets
Exhaust fan
Lighting1
Electrical outlets

OTHER EQUIPMENT
Heating Equipment
Air-conditioning unit(s)
Hot-water heater
Smoke/Fire alarms
Thermostat
Door bell

TOTAL
1. Fixtures, Bulbs, Switches, and Timers
2. Floor/Walls/Ceiling, Shelves/Rods, Lighting
3. Water pressure and Hot water

HUD Occupancy Handbook
Appendix 5: Move-In/Move-Out Inspection Format

3

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4350.3 REV-1

Appendix 5

Move-Out

Move-In
This inspection report represents the
condition of the unit. Any deficiencies
identified in this report will be remedied
within 30 days of the date the tenant
moves into the unit.

_______________________________
Manager's Signature

_______________________________
Manager's Signature

Agree with move-out inspection
Disagree with move-out inspection

I have inspected the apartment and
found it to be in good condition,
excepting the items noted above. I
recognize that I am responsible for
keeping the apartment in good
condition, with the exception of normal
wear. In the event of damage, I agree
to pay the cost to restore the apartment
to its original condition.

If disagree, list specific items of
disagreement.

_______________________________
Resident's Signature

_______________________________
Resident's Signature

_______________________________
Resident's Signature

_______________________________
Resident's Signature

By

Date

By

Prepared

Prepared

Reviewed

Reviewed

Prepared

Prepared

Reviewed

Reviewed

5/03

4

Date

HUD Occupancy Handbook
Appendix 5: Move-In/Move-Out Inspection Format

Appendix 6
Completing the 50059 Data Requirements
When the Owner Must Fully Complete the
Data Requirements and When the Owner
Partially Completes Them

4350.3 REV-1

Appendix 6

Appendix 6: Completing the 50059 Data Requirements
When the Owner Must Fully Complete the Data Requirements and When the
Owner Partially Completes Them
Refer to Chapter 5 for the business rules to use in completing the 50059 data requirements.
The data requirements for these certifications are identified in Appendix 7. The current TRACS
MAT Guide contains information about the specific data requirements. The MAT Guide, which
is referenced in Figure 9-7, is available from the HUD TRACS Internet site
[www.hud.gov/offices/hsg/mfh/trx/trxsum.cfm]. This appendix is based on MAT Guide,
TRACS Release 2.0.1.B. Because TRACS will be updated more often than this handbook,
property owners should always check the TRACS Internet site for updated versions and
changes.
I.

Actions for Which Owners MUST FULLY Complete the Owner and Tenant Data
Requirements
NOTE: Signatures by the head, spouse, co-head, all adult members of the household
and the owner are required on the 50059 facsimile.
A.

Move-ins.

B.

Initial certifications.

C.

Annual recertifications.

D.

Interim recertifications.

E.

When converting a Rent Supplement or RAP tenant to Section 8.

F.

When a HUD-owned project is sold and a tenant begins to receive Section 8 as a
result of the sale.

G.

When correcting a previous full submission.

H.

When there is a change in the person who is head of household.

HUD Occupancy Handbook
Appendix 6: Completing the 50059
Data Requirements

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Appendix 6

4350.3 REV-1

II.

Actions for Which Owners MUST PARTIALLY Complete the 50059 Data
Requirements
A.

B.

For the following actions, owners are only required to submit a partial set of
50059 data requirements.
1.

Address change.

2.

Move-out.

3.

Termination of assistance.

4.

Unit transfer.

5.

Gross rent change.

Owners must follow the procedures below to meet the data requirements for
these actions. These procedures ensure that TRACS has up-to-date information
regarding tenants at a property.
1.

Complete the items of the 50059 data requirements listed below for the
particular transaction being performed. Also complete Section A from
Appendix 7 to identify the partial certification.

2.

Obtain signatures on a facsimile of partial submissions where indicated
by the presence of Owner Signed Date (MAT Field 78 in MAT10 Section
2: Basic Record) and Tenant Signed Date (MAT Field 77 in MAT10
Section 2: Basic Record) and file in the tenant file.
NOTE: If State law or landlord/tenant ordinances require tenant
signatures on a facsimile for certain transactions, and such signatures are
not indicated in this appendix, then the owner must obtain tenant
signatures in accordance with local or State law or ordinance.

C.

Tenant Address
The following MAT fields listed in Figure 1 must be submitted to process a
change of tenant address, record a tenant address different than the unit address
and delete a tenant address in TRACS.

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HUD Occupancy Handbook
Appendix 6: Completing the 50059
Data Requirements

4350.3 REV-1

Appendix 6

Figure 1: Tenant Address Change Data Requirements
MAT15: Address Record
MAT
Field

Note

4

MOC

Field Name
Head of
Household ID

Field Type
Alphanumeric

Definitions and Edits
•

The SSN/TRACS ID of the Head of Household.
Enter 999999999 if the head of household is
present but has no SSN/TRACS ID.

•

Head of Household ID Code is required if the
unit is occupied and assisted. If the unit is
unoccupied or unassisted at the time of the
Unit Address Load, the Head of Household ID
Code is not required.

•

When the head of the household occupying the
unit has no SSN or “T-ID,” the name and birth
date will be required and the Head of
Household ID Code field is to be 9-filled.

•

Head of Household ID Code is required for a
tenant mailing address MAT15.

5

MOC

Head Last
Name

Alphanumeric

Required if the unit is occupied, but the head of
household has no SSN and the owner does not
have the tenant’s “T-ID.” Not required for
unoccupied or unassisted units.

6

MOC

Head First
Name

Alphanumeric

Required if the unit is occupied, but the head of
household has no SSN and the owner does not
have the tenant’s “T-ID.” Not required for
unoccupied or unassisted units.

7

MOC

Head Middle
Initial

Alphanumeric

Required if the unit is occupied, but the head of
household has no SSN and the owner does not
have the tenant’s “T-ID.” Not required for
unoccupied or unassisted units. Blanks are
accepted in this field.

8

MOC

Head Birth Date

Date

Required if the unit is occupied, but the head of
household has no SSN and the owner does not
have the tenant’s “T-ID.” Not required for
unoccupied or unassisted units.

MMDDYYYY
9

F

Building ID

Alphanumeric

M = Mandatory field; has a value not equal to spaces or zeros. MOC = Mandatory on condition(s). F = Future field;
TRACS will value with the appropriate fill characters.
HUD Occupancy Handbook
Appendix 6: Completing the 50059
Data Requirements

3

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Appendix 6

4350.3 REV-1

MAT15: Address Record
MAT
Field

Note

10

MOC

Field Name
Unit Number

Field Type
Alphanumeric

Definitions and Edits
•

Unit Number is mandatory for a MAT15 Unit
Address Add/Update transaction. It is not
required for a Tenant Mailing Address.

•

Unit Number must be entered using a standard
format for the project that meets the “unique
within a project” requirement.

•

This must be the same format used when “Unit
Number” is entered in (re)certifications
(MAT10), move-outs (MAT40), and unit
transfers (MAT70).

11

MOC

Previous Unit
Number

Alphanumeric

The Previous Unit Number is required only when the
MAT15 is submitted to change the Unit Number or
Address. This field must be populated for unit
address change transactions, using the previous
Unit Number exactly as it was submitted to TRACS.
The Previous Unit Number is required even if the
Unit Number is not the address element being
changed. The previous unit number is also required
when using the MAT15 to renumber units within the
project. The MAT15 will be rejected if TRACS
cannot find the previous unit number.

12

M

Address Type

Alphanumeric

Identifies Unit or Mailing Address. A Head of
Household ID Code is required for mailing
addresses. Values are:
“U” = Unit Address
“M” = Mailing Address (if different from Unit
Address)

13

M

Transaction
Type

Numeric

Valid Transaction Type action by owner/agents are:
1 = Address Deletion
2 = Address Add/Update (Used for both initial loads
and updates)
3 = Renumber Unit

14

MOC

First Address
Line

Alphanumeric

First Address Line is required for an Address initial
load or update. It should contain the unit number
meeting the requirements for mail delivery by the
USPS. For a tenant mailing address, the First
Address Line can be used for a “care of” or
“attention” name. First Address Line is not required
for an Address Deletion.

M = Mandatory field; has a value not equal to spaces or zeros. MOC = Mandatory on condition(s). F = Future field;
TRACS will value with the appropriate fill characters.
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HUD Occupancy Handbook
Appendix 6: Completing the 50059
Data Requirements

4350.3 REV-1

Appendix 6

MAT15: Address Record
MAT
Field

Note

Field Name

Field Type

Definitions and Edits

15

Second Address
Line

Alphanumeric

Second Address Line.

16

Third Address
Line

Alphanumeric

Third Address Line.

17

MOC

City Name

Alphanumeric

Required on an Address Load or Address Update
transaction.

18

MOC

State Code

Alphanumeric

Required on an Address Load and an Address
Update transaction.

19

MOC

Zip – 5

Numeric

Required on an Address Load and an Address
Update transaction. For codes see United States
Postal Services Publication 65, available from local
post office.

Zip – 4

Numeric

Must enter all zeros when no ZIP-4 is provided.

Mobility
Accessibility
Code

Alphanumeric

Identifies unit’s accessibility status for tenants with
mobility impairments.

20
21

M

Values are:
Y = Accessible for Mobility Impaired
N = Not Accessible for Mobility Impaired.

22

M

Hearing
Accessibility
Code

Alphanumeric

Identifies unit’s accessibility status for tenants with
hearing impairments.
Values are:
Y = Accessible for the Hearing Impaired
N = Not Accessible for the Hearing Impaired.

23

M

Visual
Accessibility
Code

Alphanumeric

Identifies unit’s accessibility status for tenants with
visual impairments.
Values are:
Y = Accessible for the Visually Impaired
N = Not Accessible for the Visually Impaired.

M = Mandatory field; has a value not equal to spaces or zeros. MOC = Mandatory on condition(s). F = Future field;
TRACS will value with the appropriate fill characters.
HUD Occupancy Handbook
Appendix 6: Completing the 50059
Data Requirements

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Appendix 6

4350.3 REV-1

D.

Move-Out
The following MAT fields listed in Figure 2 must be submitted to process a moveout in TRACS.
Figure 2: Move-Out Data Requirements
MAT40 Move-Out Record

MAT
Field

Note

Field Name

Field Type

4

M

Transaction
Type

Alphanumeric

Value = MO

5

M

Head of
Household ID
Code

Alphanumeric

The SSN/TRACS ID of the Head of Household.
Enter 999999999 if the head of household has no
SSN/TRACS ID, and submit the Head of
Household's name and birth date.

6

MOC

Head Last
Name

Alphanumeric

Required only if the head of household has no SSN
and the owner does not have the tenant's "T-ID.”

7

MOC

Head First
Name

Alphanumeric

Required only if the head of household has no SSN
and the owner does not have the tenant's "T-ID.”

8

MOC

Head Middle
Initial

Alphanumeric

Required only if the head of household has no SSN
and the owner does not have the tenant's "T-ID.”

9

MOC

Head Birth Date

Date

Required only if the head of household has no SSN
and the owner does not have the tenant's "T-ID.”

MMDDYYYY
10

M

Move-Out Date

Date

Definitions and Edits

The date the tenant moved out of the project.

MMDDYYYY
11

M

Unit Number

Alphanumeric

The unit from which the tenant moved. The unit
number must exist in the TRACS address table and
be associated with the tenant moving out:
otherwise, a discrepancy message will be returned
to the sender.

12

F

Building ID

Alphanumeric

The building from which the tenant moved.

M = Mandatory field; has a value not equal to spaces or zeros. MOC = Mandatory on condition(s). F = Future field;
TRACS will value with the appropriate fill characters.
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HUD Occupancy Handbook
Appendix 6: Completing the 50059
Data Requirements

4350.3 REV-1

Appendix 6

MAT40 Move-Out Record
MAT
Field

Note

13

M

Field Name

Field Type

Move-Out Code

Alphanumeric

Definitions and Edits
The valid codes are:
1 = Owner initiated for nonpayment of rent
2 = Owner initiated other than nonpayment of rent
3 = Tenant initiated
4 = Death of sole family member
5 = Unit Transfer between two contracts or projects

14

MOC

Date of Death

Date
MMDDYYYY

Required if the Move-Out Code is "4." The unit is to
be vacated within 14 days of the date of death of
the sole household member. TRACS will generate
a discrepancy if the Move-Out Date is greater than
14 days following the date of death.

15

M

Voucher Date

Date

The voucher period in which the move-out
adjustment is reflected.

16

F

Correction Type

Alphanumeric

1 = Reserved
2 = Corrects owner/agent error
3 = Corrects tenant misreporting error

17

F

Transaction
Effective Date of
Move-Out Being
Corrected

Date

This is a "MOC" field. It must be populated if the
Correction Type is populated. For corrections to
Move-Outs, enter the Transaction Effective Date of
the full certification to which the move-out was
applied. If the move-out was applied to the wrong
certification occurrence, delete the move-out
(MAT20) and resubmit with the appropriate
Transaction Effective Date in the Move-Out
transaction.

M = Mandatory field; has a value not equal to spaces or zeros. MOC = Mandatory on condition(s). F = Future field;
TRACS will value with the appropriate fill characters.
HUD Occupancy Handbook
Appendix 6: Completing the 50059
Data Requirements

7

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Appendix 6

4350.3 REV-1

E.

Termination of Assistance
The following MAT fields listed in Figure 3 must be submitted to process a
termination of assistance in TRACS.
Figure 3: Termination of Assistance Data Requirements
MAT65 Termination Record

MAT
Field

Note

Field Name

Field Type

Definitions and Edits

4

M

Transaction
Type

Alphanumeric

Value = TM

5

M

Head of
Household ID
Code

Alphanumeric

The SSN/TRACS ID of the Head of Household.
Enter 999999999 if the head of household has no
SSN/TRACS ID, and enter the Head of Household's
name and birth date.

6

MOC

Head Last
Name

Alphanumeric

Required only if the head of household has no SSN
and the owner does not have the tenant's "T-ID.”

7

MOC

Head First
Name

Alphanumeric

Required only if the head of household has no SSN
and the owner does not have the tenant's "T-ID.”

8

MOC

Head Middle
Initial

Alphanumeric

Required only if the head of household has no SSN
and the owner does not have the tenant's "T-ID.”

9

MOC

Head Birth Date

Date

Required only if the head of household has no SSN
and the owner does not have the tenant's "T-ID.”

10

M

Term Effective
Date

Date
MMDDYYYY

The date this termination became or will become
effective.

M = Mandatory field; has a value not equal to spaces or zeros. MOC = Mandatory on condition(s). F = Future field;
TRACS will value with the appropriate fill characters.
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HUD Occupancy Handbook
Appendix 6: Completing the 50059
Data Requirements

4350.3 REV-1

Appendix 6

MAT65 Termination Record
MAT
Field

Note

11

M

Field Name
Termination
Code

Field Type
Alphanumeric

Definitions and Edits
Valid Termination Codes:
TI = Equals/Exceeds Gross Rent (Replaces "TTP").
TC = Did not supply citizenship/eligible alien
documentation.
TR = Did not recertify on time. Tenant required to
pay market rent.
TF = Tenant refused to transfer as agreed or
submitted false data.
CE = Subsidy contract expired or combined with a
renewal contract.
The following codes are reserved for HUD use
only.
EN = Contract terminated for enforcement action.
HQ = TRACS generated termination for failure to
recertify or failure to submit a termination or moveout.

12

Description

Alphanumeric

Free-form text.

13

F

Building ID

Alphanumeric

The building in which the tenant lives.

14

M

Unit Number

Alphanumeric

The unit in which the tenant lives.

15

M

Voucher Date

Date

The date of the voucher in which the termination is
reflected. NOTE: "DD" is always "01".

MMDDYYYY:
16

F

Correction Type

Alphanumeric

1 = Reserved
2 = Corrects owner/agent error
3 = Corrects tenant misreporting error

17

F

Transaction
Effective Date of
Termination
Being Corrected

Date

This is a "MOC" field. It must be populated if the
Correction Type is populated. For corrections to
Terminations, enter the Transaction Effective Date
of the full certification to which the termination was
applied. If the termination was applied to the wrong
certification occurrence, delete the termination
(MAT20) and resubmit with the appropriate
Transaction Effective Date in the termination
transaction.

M = Mandatory field; has a value not equal to spaces or zeros. MOC = Mandatory on condition(s). F = Future field;
TRACS will value with the appropriate fill characters.
HUD Occupancy Handbook
Appendix 6: Completing the 50059
Data Requirements

9

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Appendix 6

4350.3 REV-1

F.

Unit Transfer/Gross Rent Change
The following MAT fields listed in Figure 4 must be submitted to process a unit
transfer or gross rent change in TRACS.
1.

Unit Transfers: Instructions vary depending on whether the transfer
within the project is between the same contract or between two different
contracts.
NOTE: In electronically transmitting certification data, “project” includes
buildings located on adjacent sites and managed as one project, even if
the buildings have separate mortgages and/or project numbers.
a.

Unit transfer within the same contract. If the transfer occurs
within the same contract, consider it as a unit transfer (UT).
Complete the following 50059 data requirements listed in Figure 4.

b.

Unit transfer between two contracts. First process a termination
(MAT 65) using the termination code CE (CE = Subsidy contract
expired or combined with a renewal contract), and then process
an initial certification (IC) for this tenant by fully completing the
50059 data requirements in Appendix 7. Because this is the same
project, the tenant is not subject to admission and eligibility
requirements.
NOTE: The next recertification date will change because of this
action, and the owner should change it back to the former
recertification anniversary date.

NOTE: If a unit transfer occurs in conjunction with an annual
recertification, it is considered an annual recertification, not a transfer,
and the owner must fully complete the data requirements in Appendix 7.
2.

Gross Rent Changes: If the gross rent change occurs in conjunction with
an annual recertification, then the action is not a gross rent change. It is
an annual recertification and a complete recertification is required. See
Appendix 7.
NOTE: Complete the items marked with an asterisk (*) only if the rent
changes as a result of the unit transfer or a gross rent change.

M = Mandatory field; has a value not equal to spaces or zeros. MOC = Mandatory on condition(s). F = Future field;
TRACS will value with the appropriate fill characters.
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HUD Occupancy Handbook
Appendix 6: Completing the 50059
Data Requirements

4350.3 REV-1

Appendix 6

Figure 4: Unit Transfer and Gross Rent Change Data Requirements
MAT70 Unit Transfer/Gross Rent Change Record
MAT
Field

Note

4

M

Field Name

Transaction
Type

Field Type

Alphanumeric

Definitions and Edits

Values are:
GR = Gross Rent Change
UT = Unit Transfer
NOTE: Unit Transfers can only be used if the
project number and contract number do not change.
Otherwise, a Move-Out and an Initial Certification is
used to effect the transfer.

5

M

Head of
Household ID
Code

Alphanumeric

The SSN/TRACS ID of the Head of Household.
Enter 999999999 if the Head of Household has no
SSN/TRACS ID, and enter the Head of Household's
name and birth date.

6

MOC

Head Last
Name

Alphanumeric

Required only if the Head of Household has no SSN
and the owner does not have the tenant's "T-ID.”

7

MOC

Head First
Name

Alphanumeric

Required only if the Head of Household has no SSN
and the owner does not have the tenant's "T-ID.”

8

MOC

Head Middle
Initial

Alphanumeric

Required only if the Head of Household has no SSN
and the owner does not have the tenant's "T-ID.”

9

MOC

Head Birth Date

Date

Required only if the Head of Household has no SSN
and the owner does not have the tenant's "T-ID.”

10

M

Transaction
Effective Date

Date

The date this transaction (gross rent change or unit
transfer) is effective.

MMDDYYYY

11

M

New Unit
Number

Alphanumeric

The unit into which the tenant is moving (the unit
number must be unique within a project). Enter
9999999999 if this transaction is for a rent change
only and there is no change in unit number.

12

F

Building ID

Alphanumeric

The building into which the tenant is moving.

M = Mandatory field; has a value not equal to spaces or zeros. MOC = Mandatory on condition(s). F = Future field;
TRACS will value with the appropriate fill characters.
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4350.3 REV-1

MAT70 Unit Transfer/Gross Rent Change Record
MAT
Field

Note

14

M

Field Name

New Contract
Rent Amount*

Field Type

Numeric

Definitions and Edits

Contract/Basic Rent. Enter the rent HUD or the
Contract Administrator has approved for this unit.
The Contract Rent is the Section 8 RAP Contract
Rent, the Section 236 Basic Rent, the Section
221(d)(3) BMIR Rent or the Rent Supplement unit
rent, as applicable. Obtain this amount from the
project's Rental Schedule (Form HUD-92458) or
subsidy contract.
For Section 202 PAC or PRAC and Section 811
PRAC projects, if the tenant pays utilities
separately, enter the operating rent (operating cost)
minus the HUD-approved utility allowances. If all
utilities are included in the rent, enter the operating
rent.
Enter 9999 (all 9's) if this transaction is for a unit
transfer only and there is no change in contract rent.

15

16

Tenant Rent*

Total Tenant
Payment*

Numeric

The amount payable monthly by the family as rent
to the owner.

Numeric

•

Where all utilities (except telephone) and
other essential housing services are supplied
by the owner, tenant rent equals total tenant
payment.

•

Where some or all utilities (except telephone)
and other essential housing services are not
supplied by the owner, tenant rent equals
total tenant payment less the utility
allowance.

The total amount the HUD rent formula requires the
tenant to pay toward the gross rent. Total Tenant
Payment is computed in accordance with the
formula in Exhibit 5-9.
Enter 0 if not applicable.

17

Gross Rent*

Numeric

The sum of the contract rent and any utility
allowance. If there is no utility allowance, the gross
rent equals the contract rent. For Section 202 and
Section 811 PRAC projects, the gross rent is
referred to as the operating rent.
Enter total of Contract/Basic Rent and Utility
Allowance.

M = Mandatory field; has a value not equal to spaces or zeros. MOC = Mandatory on condition(s). F = Future field;
TRACS will value with the appropriate fill characters.
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4350.3 REV-1

Appendix 6

MAT70 Unit Transfer/Gross Rent Change Record
MAT
Field

Note

18

Field Name

Utility Allowance
Amount*

Field Type

Numeric

Definitions and Edits

HUD’s or the Contract Administrator’s estimate of
the average monthly utility bills (except telephone)
for an energy-conscious household. This estimate
considers only utilities paid directly by the tenant. If
all utilities are included in the rent, there is not a
utility allowance. Utility allowances vary by unit type
and are listed on the project’s rent schedule or HAP
contract.
If all utilities are included in the rent, enter 0.
Otherwise, enter the amount HUD or the Contract
Administrator has approved for this unit type. This
amount can be obtained from the project's Rental
Schedule (Form HUD-92458) or subsidy contract.

19

Utility
Reimbursement*

Numeric

The amount, if any, by which the utility allowance for
a unit exceeds the total tenant payment for the
family occupying the unit.
NOTE: If this is a mixed family as defined in
paragraph 3-12 B.5, Restrictions on Assistance to
Noncitizens (or later instruction), consult with
Chapter 5 on how to complete this item.
Submit prorated amount for prorated tenant.
Prorated amounts are for noncitizen households
only.

20

Assistance
Payment
Amount*

Numeric

The monthly amount that HUD pays toward a
tenant’s rent and utility costs. These payments
include Rent Supplement, RAP, PAC, PRAC, and
Section 8 regular monthly payments.
NOTE: Section 8 special claims payments or
interest reduction payments which are paid monthly
to mortgagees on behalf of Section 236 projects are
not considered assistance payments.
Enter 0 if not applicable. A negative assistance
payment amount is only valid for a PRAC unit.
Submit prorated amount for prorated tenant.
NOTE: Enter negative numbers with the sign in the
leftmost position and the number right-adjusted and
zero filled (e.g., –00045). Positive values are
unsigned.

21

M

Voucher Date

Date
(MMDDYYYY)

(MMDDYYYY): The date of the voucher being
affected by the Unit Transfer or Gross Rent Change.
Note: "DD" is always "01."

M = Mandatory field; has a value not equal to spaces or zeros. MOC = Mandatory on condition(s). F = Future field;
TRACS will value with the appropriate fill characters.
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MAT70 Unit Transfer/Gross Rent Change Record
MAT
Field

Note

22

MOC

Field Name

Previous Unit
Number

Field Type

Definitions and Edits

Alphanumeric

The Previous Unit Number is required if the MAT70
is a unit transfer (New Unit Number is not equal to
"9999999999").

REMEMBER: Complete the items marked with an asterisk (*) only if the rent changes as a
result of the unit transfer.

M = Mandatory field; has a value not equal to spaces or zeros. MOC = Mandatory on condition(s). F = Future field;
TRACS will value with the appropriate fill characters.
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Appendix 7
The 50059 Data Requirements

4350.3 REV-1

Appendix 7

Appendix 7: The 50059 Data Requirements
Owners are required to electronically transmit tenant data from certifications and recertifications
to HUD/Contract Administrator via the Tenant Rental Assistance Certification System (TRACS).
This appendix serves as the basis for the certifications that must be signed by the tenant and
the owner regarding the data that they each provide for the 50059 data requirements. It also
contains the required data elements for electronic transmissions.
See Chapter 5 of HUD Handbook 4350.3 for the business rules, which support the data
requirements in this appendix and the requirements to electronically transmit this data in the
HUD TRACS MAT guide. This chapter also contains the requirements concerning the owner
and tenant certifications. Consult with Chapter 5 regarding verification requirements for any
information that is entered into these 50059 data requirements. Refer to the TRACS
Information Packet (see Additional Program Resources in Chapter 1) for technical information
about 50059 data requirements and data submissions.
U.S. Department of Housing and Urban Development
OMB Approval #2502-0204 (exp. 10/31/2004)
1

Note:
See Chapter 5 of HUD Handbook 4350.3. This chapter sets out the required elements
for certifications. Appendix 7 contains the instructions for completing each field
contained in the certification. The following format is provided as an example only.

2

Notice to Owners:
Penalties for Misusing Applicant and Tenant Information: Title 18, Section 1001 of the
U.S. Code states that a person is guilty of a felony for knowingly and willingly making
false or fraudulent statements to any department of the U.S. Government. HUD, the
Public Housing Authority (PHA), and any owner (or any employee of HUD, the PHA, or
the owner), may be subject to penalties for unauthorized disclosures or improper uses of
information collected from the applicant or tenant. Any person who knowingly or willfully
requests, obtains, or discloses any information under false pretenses concerning an
applicant or tenant may be subject to a misdemeanor and fined not more than $5,000.
Any applicant or tenant affected by negligent disclosure of information may bring civil
action for damages, and seek other relief, as may be appropriate, against the officer or
employee of HUD, the PHA, or the owner responsible for the unauthorized disclosure or
improper use.

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4350.3 REV-1

3

Privacy Act Notice to Tenants:
The Department of Housing and Urban Development (HUD) is authorized to collect this
information by the U.S. Housing Act of 1937, as amended (42 U.S.C. 1437 et seq.); the
Housing and Urban-Rural Recovery Act of 1983 (P.L. 98-181); the Housing and
Community Development Technical Amendments of 1984 (P.L. 98-479); and by the
Housing and Community Development Act of 1987 (42 U.S.C. 3543). The information is
being collected by HUD to determine an applicant's eligibility, the recommended unit
size, and the amount the tenant(s) must pay toward rent and utilities. HUD uses this
information to assist in managing certain HUD properties, to protect the government's
financial interest, and to verify the accuracy of the information furnished. HUD or a PHA
may conduct a computer match to verify the information you provide. This information
may be released to appropriate federal, State, and local agencies, when relevant, and to
civil, criminal, or regulatory investigators and prosecutors. However, the information will
not be otherwise disclosed or released outside of HUD, except as permitted or required
by law. You must provide all of the information requested. Failure to provide any
information may result in a delay or rejection of your eligibility approval.

4

Public Reporting Burden:
The reporting burden for this collection of information is estimated to average one hour
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. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden, to
the Reports Management Officer, Office of Information Policies and Systems, U.S.
Department of Housing and Urban Development, Washington, D.C. 20410-3600; and to
the Office of Management and Budget, Paperwork Reduction Project (2502-2024),
Washington, D.C. 20503.

5

Include the following certification to be signed and dated by the owner (or
designated agent):
“Warning to Owners: Your signature indicates that you agree with this certification
statement. The 50059 data requirements: I certify that this Tenant's eligibility, rent, and
assistance payment have been computed in accordance with HUD's regulations and
administrative procedures and that all required verifications were obtained. I also certify
that the computations are based upon the data provided by the Tenant. I have read and
understand the purpose and uses of collecting the required information from applicants
and tenants and I understand that misuse of this information can lead to personal
penalties to me."

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4350.3 REV-1

Appendix 7

6

Include the following certification statement to be signed and dated by the
family head, any spouse or co-head, and all adult family members:
"Warning to Tenants: Your signature means that you agree with the following
certification statements. This certification covers the information provided by the
Applicant/Tenant in Sections C, D, and E of the 50059 data requirements (see below).
This information is used in determining eligibility or the level of benefits.”
I/We certify that the information I/we have provided is true and complete to the best of
my/our knowledge and belief.
I/We understand that, if I/we furnish false or incomplete information, I/we can be fined up
to $10,000 or imprisoned up to five years, or lose the subsidy HUD pays and have
my/our rent increased.
I/We have read the Privacy Act Notice.

The 50059 data requirements are divided into five areas:
A.

Summary (or Header) Record
This record counts and totals the four other areas for the certification.

B.

Basic Record
There is a single basic record for this certification. It brings together those
records needed to determine Total Tenant Payment, Tenant Rent, Assistance
Payment, etc.

C.

Household (Family) Record
There is a single basic record for each household member for the certification. It
generally tracks the previous Part II. Household Composition.

D.

Income Record
There is a record for every income source for each household member.

E.

Asset Record
There is a record for each asset source for each household member.

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Section A. Summary (or Header) Record
59
Field

Field Name

Definition

A1.

Project Name

Enter the project name that appears on the regulatory agreement or
subsidy contract. This will be the current project name in the Contracts
database. If there is a discrepancy with Contracts, the name submitted
on the data requirements will not be stored by TRACS.

A2.

Subsidy Type (C – 3)

Enter the code for the subsidy the tenant will receive during the period
covered by this submission. Enter only one code.
0 = Zero is used with MAT15 Address Records to establish addresses
for unoccupied units that are not assisted by one of the subsidies listed
below or for market rent tenants that are not in Section 236 or Section
221(d)(3) BMIR units.
1 = Section 8
2 = Rent Supplement
3 = RAP
4 = Section 236
5 = Section 221(d)(3) BMIR
6 = Reserved
7 = Section 202 PRAC
8 = Section 811 PRAC
9 = Section 202/162 PAC
If a tenant receives Section 8, Rent Supplement, or RAP assistance in
a project that is also subsidized through Section 236 or Section
221(d)(3) BMIR, enter only the "deeper" subsidy (i.e., Section 8, Rent
Supplement, or RAP).
Use Code 1 (Section 8) only for Section 8 assistance that is the result
of a project-based Section 8 contract for the project. Do not enter Code
1 for tenants who receive Section 8 Rental Certificate or Rental
Voucher assistance; instead, enter the appropriate subsidy code for
these tenants (Section 236, [4] or Section 221(d)(3) BMIR [5]).

A3.

Property ID

[Future Field.]

A4.

Project Number

Enter the 8-digit FHA, Elderly Housing, or State Agency noninsured
project number. Do not enter dashes or a subsidy suffix (e.g., SUP,
RAP). Sample entries are provided below.
FHA Insured Project

12144026

Elderly Housing Projects

121EH00l

Other Noninsured Projects

121001N1

NOTE: Previously, owners entered "FmHA" for RHS Section 515/8
projects. This is no longer required.

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4350.3 REV-1

Appendix 7

Section A. Summary (or Header) Record
59
Field
A5.

Field Name
Contract Number

Definition
Complete for Section 8 projects (including State Agency and USDA
RHS 515/8 projects), Section 202 PAC projects, Section 202 PRAC,
and Section 811 PRAC projects.
Enter the 11-digit subsidy contract number (e.g., CA26L000001). Do
not enter dashes.

A6.

Total Records Sent

The total number of physical records sent in this transmission, including
this header record and the TENND record. A physical record is each
TENXX, each MATXX record and each section record for those
MATXX records that have section records.

A7.

Project’s Telecom
Address

The project’s telecommunications identifier assigned by HUD.
Positions 1 through 5 must contain “TRACM.” The last five positions
are the HUD assigned number.

A8.

OA Transmission
Date

Format: MMDDYYYY
This is a system date stamp representing the date this file was sent by
the Owner or Contract Administrator (CA) to TRACS, or by the Owner
to the CA. No dashes or spaces should be used in this field.

A9.

OA Software Vendor

Name of the software product used by the owner or CA to create this
submission. If the software was developed in-house, enter “Developed
In-House.”

A10.

Release/Version

The release or version number associated with the software used by
the owner or CA to create this submission. Enter “N/A” if no Release or
Version identification exists.

A11.

Contract Administrator
(CA) ID

Mandatory for Contract Administrator submissions to TRACS:
Enter the five-character CA ID assigned by the HUD accounting
system.

A12.

Sender’s Telecom
Address

Mandatory for Contract Administrators or other entities receiving
submissions and forwarding them to TRACS. The
telecommunications identifier assigned by HUD to the sender
submitting the data to TRACS. Positions 1-5 must contain “TRACM.”

A13.

CA Transmission Data

Mandatory for Contract Administrators or other entities receiving
submissions and forwarding them to TRACS. Format: MMDDYYYY
This is a system date stamp representing the date this file was sent to
TRACS by the CA or third party. No dashes or spaces should be used
in this field.

A14.

CA Software Vendor

Mandatory for Contract Administrators or other entities receiving
submissions and forwarding them to TRACS. Name of the software
product used by the CA or third party to create this submission. If the
software was developed in-house, enter “Developed InHouse.”

A15.

CA Software
Release/Version

Mandatory for Contract Administrators or other entities receiving
submissions and forwarding them to TRACS. The release or
version number associated with the software used to create this file.
Enter “N/A” if no Release or Version identification exists.

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Section A. Summary (or Header) Record
59
Field
A16.

Field Name

Definition

Agency Defined Data

Reserved for the use of CA or other entities receiving submissions and
forwarding them to TRACS. This field may contain any value the
agency wishes to use. Its purpose is to provide a way for the agency to
track their transmissions or for any other purpose. These data will be
returned as a field in the HUD transmission acknowledgment.

Section B. Basic Record
59
Field

Field Name

Definition

B1.

Owner Generated
Tenant ID Number
(Optional)

Owners or CAs may enter a tenant ID number that assists the owner in
tracking tenants. All TRACS transmissions to the owner or CA will
include this ID number. TRACS will not edit this ID number nor will it
display this ID number on any screens or reports.

B2.

Previous Head ID

Enter the social security number (SSN) of the Head. If the previous
Family Head does not have an SSN, enter the number generated by
TRACS ("T" is the first character) or if TRACS has not previously
assigned a number for this person, enter 999999999.

B3.

Previous MAT10
Effective Date

MMDDYYYY. Code a value only if the head of household identifiers
(Head of Household ID or certification Effective Date) of a previous
MAT10 have changed. This value should be the Certification Effective
Date, identifying the previous MAT10 for this head of household.

B4.

Previous Head Last
Name

Enter the last name.

B5.

Previous Head First
Name

Enter the first name.

B6.

Previous Head Middle
Initial

Enter the middle initial.

B7.

Previous Head Birth
Date

Enter the birth date of the previous Family Head.

B8.

FIPS County Code

The Federal Information Processing Standards code designating the
county in which the project is located. [Future Field.]

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Appendix 7

Section B. Basic Record
59
Field
B9.

Field Name
Transaction Effective
Date

Definition
Enter the date the action in this transaction is to be effective:
Move-in Certification (MI): This is the date the tenant moved into the unit. See
Field 11 of Appendix 10, Form HUD 52670A-Part 1.
Initial Certification (IC): This is the date the tenant began to receive the type of
subsidy checked in 59 Field A2, Subsidy Type, of the 50059 data requirements.
Annual Recertification (AR): This is the effective date of Annual Recertification.
(See Chapter 7, Section 1: Annual Recertification, of HUD Handbook 4350.3.)
Interim Recertification (IR): This is the effective date of Interim Recertification.
(See Chapter 7, Section 2: Interim Recertification, of HUD Handbook 4350.3.)
Move-Out (MO): The last full day a tenant remains in occupancy. When a
tenant moves midday, the move-out date is the day prior. For move-outs
without notice, enter the date management takes possession of the unit. For
the death of the sole family member, enter the date provided by paragraph 9.12
E in HUD Handbook 4350.3, which is the earlier of a) 14 days after the tenant
died, or b) the day the unit was vacated.
Termination of Assistance (TM): See Chapter 8, Section 1: Termination of
Assistance, of HUD Handbook 4350.3.
Unit Transfer Transaction (UT): The date this transaction (gross rent change or
unit transfer) is effective.
Gross Rent Change (GR): This is the effective date of Gross Rent Change.
Prevalidation Transaction (PV): [Future Field].
Conversion from RAP to Section 8 certification effective date to Section 8 (CR):
This is the date on which the tenant begins to receive Section 8 assistance.
Conversion from Rent Supplement to Section 8 certification effective date (CS):
This is the date on which the tenant begins to receive Section 8 assistance.
Corrections to Existing Certifications (59 Field B13 is completed):
For changes in TTP determine whether any change in the tenant's TTP is
effective retroactively or prospectively, in accordance with paragraph 7-8.

B10

Project Move-In Date

MMDDYYYY
The date the tenant moved into the project.

B11.

Transaction Type

Valid Codes:

(Formerly Certification
Type)

AR = Annual Recertification (Formerly “4”)
CR = Converted from RAP to Section 8 (Formerly “2” plus Converted
from Program Type = “R”)
CS = Converted from Rent Supplement (Formerly “2” plus Converted
from Program Type = “S”)
IC = Initial Certification (Formerly “3”)
IR = Interim Recertification (Formerly “5”)
MI = Move In (Formerly “1”)

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Section B. Basic Record
59
Field
B12.

Field Name
Action Processed
Code

Definition
The valid code is:
Space = Not a correction
1 = Correction to a prior 50059. Rent rebate is not supported by
TRACS.

B13.

Correction Type Code

If the Action Processed Code is “1,” Correction Type must be
populated.
The values are:
Space = No correction
1 = Administrative Resubmissions.
2 = Corrects owner or Contract Administrator certification errors.
3 = Corrects tenant misreporting.

B14.

Effective Date of
Certification Being
Corrected

Complete this field only if:
59 Field B11, Transaction Type, reports one of the transactions listed
below:
Move-Out (MO)
Termination of Assistance (TM)
Unit Transfer (UT)
Gross Rent Change (GR)
OR
59 Field B13 reports a correction.
Enter the effective date of the certification being changed by this
transaction. This will link the current transaction to the certification that
it affects. Careful: this is not the effective date of this transaction.
Example: If a termination, effective 9/01/01, is to be processed against
a certification with an effective date of 12/01/00, the Termination of
Assistance Transaction Effective Date (59 Field B9) is 9/01/01 and the
Effective Date of the Certification Being Affected (59 Field B14) is
12/01/00.

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Appendix 7

Section B. Basic Record
59
Field
B15.

Field Name
Previous Subsidy
(Former Subsidy
Change Indicator)

Definition
The previous subsidy when there has been a change in subsidy for the
tenant or when the tenant moves from assisted to market rent or from
market rent to assisted.
Space = No previous history in this project.
0 = Market Rent Tenants not covered by Section 236 or Section
221(d)(3) BMIR)
1 = Section 8
2 = Rent Supplement
3 = RAP
4 = Section 236
5 = Section 221(d)(3) BMIR
7 = Section 202 PRAC (Capital Advance)
8 = Section 811 PRAC (Capital Advance)
9 = Section 202/162 PAC

B16.

Conversion Date
Code

Applies only to tenants converted from Rent Supplement or RAP and
who are now receiving Section 8. Values are:
1 = Converted before 10/01/81
2 = Converted between 10/01/81 and 9/30/84
3 = Converted on or after 10/01/84

B17.

Age 62 at Conversion
Indicator

Applies only to tenants converted from Rent Supplement or RAP and
who are now receiving Section 8. Values are:
Y = Head or spouse 62 on date of conversion
N = Neither head nor spouse was 62

B18.

Continuous Section 8
Indicator

Applies only to tenants converted from Rent Supplement or RAP and
who are now receiving Section 8. Values are:
Y = Received Section 8 continuously since conversion
N = Have not received Section 8 continuously since conversion

B19.

Race

Enter one code for race that best describes the family head.

NOTE: TRACS
changes are pending
on the revised racial
categories.

1 = White
2 = Black
3 = American Indian/Native American
4 = Asian/Pacific Islander

B20.

Ethnicity

Enter one code for ethnicity that best describes the Family head:

NOTE: TRACS
changes are pending
on the revised
ethnicity category.

1 = Hispanic
2 = Non-Hispanic

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Section B. Basic Record
59
Field
B21.

Field Name

Definition

Previous Housing
Code

Valid Previous Housing Codes:

Displacement Status
Code

Valid Displacement Status Codes:

B23.

Number of Family
Members

Number of Members Whose Income and Circumstances Are
Considered in Determining Annual Income: Enter the number of family
members who have one of the following relationship codes in 59 Field
C5: H, S, K, D, and O.

B24.

Number of NonFamily Members

Other Individuals Whose Income and Circumstances Are NOT
Considered in Determining Annual Income: Enter the number of
individuals who have one of the following relationship codes in 59 Field
C5: F and L.

B22.

1 = Substandard
2 = Without or Soon to Be Without Housing
3 = Standard
4 = Conventional Public Housing
(Owned by a Public Housing Agency)
1 = Government Action
2 = Natural Disaster
3 = Private Action
4 = Not Displaced

Income of these individuals is not considered in determining the
family's Annual Income. These individuals do not qualify the family for
adjustments to Annual Income, except that:
Child care expenses for the care of a foster child (F) under age
13 may be considered.
B25.

Number of
Dependents

Enter the number of persons listed as "D" in 59 Field C5 (Relationship
Code).

B26.

Total Assets

Enter the total cash value of the assets listed in 59 Field E2,
Description (Asset).

B27.

Total Income from
Assets

Enter the total of actual income from all assets in 59 Field E5 that are
anticipated to be received by the family.

B28.

Reported Passbook
Rate Percent

Enter the passbook rate as provided in HUD Handbook 4350.3,
paragraph 5-7 F, if the value of 59 Field E4, Cash Value Amount, is
greater than $5,000. Otherwise, enter zero.

B29.

Imputed Income from
Assets

Multiply the amount in 59 Field E4, Cash Value Amount, by the amount
in 59 Field B28, Reported Passbook Rate Percent (if that amount is
other than zero). If 59 Field B28 is zero, do not complete 59 Field B29
(Imputed Income from Assets.) Leave it blank.

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Appendix 7

Section B. Basic Record
59
Field

Field Name

Definition

B30.

Total Employment
Income

Includes the sum of family incomes with income codes:
B = Business
F = Federal Wage
M = Military Wage
W = Nonfederal Wage

B31.

Total Pension Income

Includes the sum of family incomes with income codes:
PE = Pensions
SI = Supplemental Security Income
SS = Social Security

B32.

Total Public
Assistance Income

Includes the sum of family incomes with income codes:
T = TANF (Formerly AFDC)
G = General Assistance

B33.

Total Other Income

Includes the sum of family incomes with income codes:
CS = Child Support
I = Indian Trust
N = Other Nonwage Source
U = Unemployment

B34.

Non-Asset Income

Enter the sum of the values entered in 59 Field D3, Income Amount, for
all family members whose income is counted.

B35.

Annual Income
Amount

Enter 59 Field B34, Non-Asset Income + (Greater of 59 Field B27,
Total Income from Assets, or 59 Field B29, Imputed Income from
Assets)

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4350.3 REV-1

Section B. Basic Record
59
Field
B36.

Field Name
Low-Income Limit
Amount

Definition
Income limits are used to establish eligibility for move-ins, initial
certifications, and Section 221(d)(3) BMIR recertification. Income limits
must be entered for all families for statistical purposes. To determine
which income limit applies to a particular family, use the number of
family members shown in 59 Field B23.
1. Section 221(d)(3) BMIR Tenants. Enter the amount of the HUDprovided Section 221(d)(3) BMIR Income Limit. If 59 Field B35 (Annual
Income Amount) is greater than 59 Field B36 (Low-Income Limit
Amount) and this is a:
Move-in, the applicant may not be admitted to a Section 221(d)(3)
BMIR unit (even if the tenant is willing to pay the market rent).
Recertification, the tenant must pay the Section 221(d)(3) BMIR market
rent.
2. All Other Tenants. Enter the HUD-provided Section 8 Low-Income
Limit (which includes PAC).
If 59 Field B35, Total Annual Income, is greater than 59 Field B36,
Low-Income Limit, and this is a move-in or an initial certification, see
HUD Handbook 4350.3 to determine if the tenant can be admitted.
If HUD Handbook 4350.3 permits you to admit this tenant, the tenant
must pay the market rent.

B37.

Very Low-Income
Limit Amount

Complete for Section 8 units, Section 202 PAC, Section 202 PRAC,
and Section 811 PRAC units. Enter the HUD-provided Section 8 Very
Low-Income Limit

B38.

Extremely LowIncome Limit Amount

Zeros if not applicable.
Required for: Section 8, not used for Section 202/162 PAC, Section
202 PRAC and Section 811 PRAC.
Less than 30% of median income.

B39.

Eligibility Universe
Code

Complete for Section 8 units only. Enter:
[1] If the HAP contract for this unit was effective before 10/1/81.
[2] If the HAP contract for this unit was effective on or after 10/1/81.

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Appendix 7

Section B. Basic Record
59
Field
B40.

Field Name
Current Income Status
Code

Definition
Section 8 Only. Enter the status of the Section 8 tenant's current
Annual Income when compared to the income limits.
[1] Lower
[2] Very Low
[3] Extremely Low
You must enter an Exception Code in (59 Field B42) for this family to
be eligible for Section 8 if the following are true:
The Income status, "lower" (Code 1), was selected in 59 Field B40;
The certification transaction type in 59 Field B11 is a Move-in or Initial
Certification (MI or IC); AND
The "post 1981" eligibility universe (Code 2) was selected in 59 Field
B39.

B41.

Section 8 Assistance
1984 Indicator

Space = Not Section 8
Y = Yes
N = No
Complete only if Eligibility Universe Code (59 Field B39) is Post-1981
(“2”) and Current Income Status Code (59 Field B40) is Lower (“1”):
otherwise, space fill.

B42.

Income Exception
Code

Complete this field if the family met the conditions listed in 59 Field
B40.
Indicate the HUD exception for which this family is eligible. These
include:
CV = The Tenant:
(1) Was converted (or is now being converted) from RAP or Rent
Supplement; or
(2) Received (or will now) begin to receive Section 8 as a result of a
sale of a HUD-owned project.
EDT = HUD approved exception for an in-place tenant who would
otherwise be displaced as described in HUD Handbook 4350.3.
EIT = Do not use for new move-ins. Continue to use this code for
tenants who previously received a HUD approved income exception.
EAT or AA = Do not use this code for new move-ins. Continue to use
this code for tenants who previously received an exception based upon
these codes.
EP = Tenant was admitted under one of the HUD-approved projectbased exceptions as described in HUD Handbook 4350.3.

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Section B. Basic Record
59
Field

Field Name

Definition

B43.

Dependent Allowance

Enter the product of $480 multiplied by 59 Field B25, Number of
Dependents.

B44.

Market Rent

Enter the HUD or Contract Administrator approved Market Rent/Section
202 PRAC and Section 811 PRAC Operating Rent.

B45.

3% of Income

Enter the product of 59 Field B35, Annual Income Amount, multiplied
by 0.03.

B46.

Disability Expense

Enter the total the family expects to pay during the 12-month period
following the Effective Transaction Date. See paragraph 5-10 C for an
explanation of disability expenses.
NOTE: If you enter expenses here, then 59 Field C14, Care Codes,
must show that an adult family member is able to work because
disability assistance is available.

B47.

Disability Allowance

1. If 59 Field B45, 3% of Annual Income, is greater than 59 Field B46,
Disability Expense, enter zero.
2.Otherwise, enter the lesser of:
59 Field B46 minus 59 Field B45 (Total Disability Assistance Expense
minus 3 percent of Income). This amount cannot exceed the total
amount of income reported in 59 Field D3, Member Income, for the
family member(s) that are coded with an "H" in 59 Field C14, Care
Code.
NOTE: If any income of a family member in 59 Field B79, Child Care
Expense A, was used to justify child care expenses that enable the
family member to work, the same income cannot also be used to justify
disability assistance expenses. However, if the income earned by the
family member (because of the disability expense) exceeds the child
care expense, any balance can be used to support a claim for disability
assistance expenses. In other words:
59 Field B79 + 59 Field B46 (Child Care Expenses Related to Family
Member Working plus Disability Expense) cannot exceed the total
amount of income in 59 Field D3 (Income Amount) that is marked with
the code CH. If the sum of these fields is greater than those fields
coded CH in 59 Field D3, reduce 59 Field B46 until the sum equals the
amount of income in 59 Field D3 that is coded CH.

B48.

5/03

Medical Expense

Enter the total amount of medical expenses the family expects to pay
(not paid or reimbursed from another source) during the 12 months
following the Transaction Effective Date. (This field only applies to
households in which the head/spouse or co-head is disabled or will be
62 or older on the effective date of this submission.) If the family will
have no medical expenses, leave this field blank.

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Appendix 7

Section B. Basic Record
59
Field
B49.

Field Name
Medical Allowance

Definition
1. If 59 Field B46, Disability Expense, is greater than or equal to 59
Field B45, 3% of Income, enter the amount from 59 Field B48, Medical
Expenses in 59 Field B49 (Medical Allowance).
2. Otherwise, enter: ([59 Field B48, Medical Expenses plus 59 Field
B46, Disability Expense] minus 59 Field B45, 3% of Income).
If the result is negative, leave this field blank.

B50.

Elderly Allowance

Enter $400 if the head/spouse or co-head is disabled, or will be 62 or
older on the effective date of this submission.

B51.

Total Allowance

Add 59 Field B43 (Dependent Allowance) + 59 Field B79 (Child Care
Expense A) + 59 Field B80 (Child Care Expense B) + 59 Field B47
(Disability Allowance) + 59 Field B49 (Medical Allowance) + 59 Field
B50 (Elderly Allowance).
Total Allowances equals the sum of the following: Allowance for
Dependents + Child Care Allowance (for working and going to school)
+ Allowable Disability Assistance Expense + Allowable Medical
Expenses + Elderly Family Allowance.

B52.

Adjusted Income
Amount

Enter 59 Field B35 (Annual Income Amount) minus 59 Field B51 (Total
Allowances)

B53.

Contract Rent Amount

Enter the rent HUD or the Contract Administrator has approved for this
unit. The Contract Rent Amount is the Section 8 RAP contract rent, the
Section 236 basic rent, the Section 221(d)(3) BMIR rent or the Rent
Supplement unit rent, as applicable. Obtain this amount from the
project's rental schedule (form HUD-92458) or subsidy contract.
For Section 202 PAC or PRAC and Section 811 PRAC projects, if the
tenant pays utilities separately, enter the operating rent (operating cost)
minus the HUD-approved utility allowances. If all utilities are included
in the rent, enter the operating rent.

B54.

Utility Allowance
Amount

If all utilities are included in the rent, enter 0. Otherwise, enter the
amount HUD or the Contract Administrator has approved for this unit
type. This amount can be obtained from the project's Rental Schedule
(form HUD-92458) or subsidy contract.

B55.

Gross Rent

Enter total of 59 Field B53 (Contract Rent Amount) and 59 Field B54
(Utility Allowance Amount).

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Section B. Basic Record
59
Field
B56.

Field Name
Welfare Rent

Definition
Enter the applicable Welfare Rent only if:
(1) The tenant will receive welfare assistance during the certification
period AND
(2) The tenant resides in an "as-paid" State or locality in which a
separate housing allowance is provided may be adjusted
(independently of the family's other welfare benefits) based upon the
family's actual housing costs. (See paragraph 5-6 I of HUD Handbook
4350.3 for additional guidance.)
Otherwise, leave this field blank (not applicable).

B57.

HCDA %

Value = 30 or 00.

B58.

Worksheet Code

Enter the Worksheet Code for the worksheet used to calculate the TTP.
Valid Worksheet Code values are: D, E, F, or G.

B59.

Minimum Rent
Hardship Exemption
Code

Required if a Section 8 tenant is claiming exemption from the $25
minimum rent. Applies only to Section 8.
Valid Codes are:
Space = Not Applicable
1 = Lost eligibility or awaiting an eligibility determination for a federal,
State, or local assistance program.
2 = Family would otherwise be evicted because it is unable to pay the
minimum rent.
3 = Family income has decreased due to changed circumstances,
including loss of employment.
4 = Death in family
5 = Other circumstances determined by the responsible entity or HUD
and includes the period during which the agent processes an
exemption request.

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Appendix 7

Section B. Basic Record
59
Field
B60.

Field Name
Total Tenant Payment

Definition
For Section 221(d)(3) BMIR and Section 236 Tenants. Leave Blank.
For Section 8, RAP, Rent Supplement, Section 202 PAC, Section 202
PRAC, and Section 811 PRAC tenants, enter the TTP as follows:
59 Field B60 (Total Tenant Payment) Section 8, RAP, and Section 202
PAC tenants. If TTP (59 Field B60) is greater than Gross Rent (59
Field B55), the family is not eligible for assistance under these
programs. Reduce the TTP to the Gross Rent.
59 Field B60 Section 202 PRAC and Section 811 PRAC tenants. Enter
TTP from 59 Field B60 even if it is greater than the Gross/Operating
Rent/Operating Costs (59 Field B55).
59 Field B60 Rent Supplement Projects. If TTP (59 Field B60) is
greater than the Gross Rent (59 Field B55), reduce the TTP to the
Gross Rent.
If this is a mixed family as defined in paragraph 3-12 and the Glossary,
consult with Exhibits 3-12, 3-13, or 3-14 on how to complete this item.

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Section B. Basic Record
59
Field
B61.

Field Name
Tenant Rent

Definition
Section 236 Tenants. Where all utilities are included in the rents
(There is no utility allowance). Enter the greater of:
•

59 Field B52 (Adjusted Income) / 12 months x .30, or

•

59 Field B53 (Contract Rent)

But never more than 59 Field B44 (Market Rent)
Where some utilities are paid by the tenant (There is no utility
allowance). Enter the greater of:
•

59 Field B52 (Adjusted Income) / 12 months x .30
minus 59 Field B54 (Utility Allowance)

•

59 Field B52 (Adjusted Income) / 12 months x .25, or

•

59 Field B53 (Contract Rent)

But never more than 59 Field B44 (Market Rent)
Section 8/RAP/Rent Supplement/Section 202 PAC, Section 202 PRAC,
and Section 811 PRAC tenants. Enter 59 Field B60 (TTP) minus 59
Field B54 (Utility Allowance). If the utility allowance is greater than the
total tenant payment, enter zero and complete 59 Field B62.
Section 221(d)(3) BMIR Tenants
(1) At initial occupancy, charge the tenant the contract rent (59 Field
B53). No special calculations or worksheets are needed.
(2) At Recertification if the tenant's annual income (59 Field B35) is:
(a) Less than or equal to 110% of the Section 221(d)(3) BMIR income
limit (59 Field B36-B38) charge the tenant the BMIR rent
(b) Greater than 110% of the Section 221(d)(3) BMIR limit, charge the
tenant the BMIR rent. (59 Field B56)
NOTE: If this is a mixed family as defined in paragraph 3.12 and the
Glossary, consult with Exhibits 3-12, 3-13, or 3-14 on how to complete
this item.
B62.

Utility Reimbursement

If utility allowance (59 Field B54) is greater than the TTP (59 Field B60)
enter the difference. Otherwise leave this item blank.
NOTE: If this is a mixed family as defined in paragraph 3-12 and the
Glossary, consult with Exhibits 3-12, 3-13, and 3-14 on how to
complete this field.

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Appendix 7

Section B. Basic Record
59
Field
B63.

Field Name
Assistance Payment
Amount

Definition
For Section 221(d)(3) BMIR and Section 236 tenants, leave blank.
For all other tenants, enter Gross Rent/PRAC Operating Rent/PAC
Operating Cost minus Total Tenant Payment.
If this amount is a negative number:
For PRAC tenants ONLY, enter the negative number.
For all other tenants, enter zero.
NOTE FOR RENT SUPPLEMENT TENANTS: If this is a move-in or an
initial certification and the assistance payment is less than 10% of the
Gross Rent, the tenant is not eligible for Rent Supplement assistance.
Recompute the tenant's rent as follows:
(1) For Section 221(d)(3) BMIR projects, charge the BMIR rent.
(2) For Section 236 projects, use the Section 236 formula to compute
the tenant's rent.
(3) For Rent Supplement projects, charge the HUD-approved market
rent.
If this is a mixed family as defined in paragraph 3-12 and the Glossary,
consult with Exhibits 3-12, 3-13, and 3-14 on how to complete this field.

B64.

% Actually Charged

Leave this blank for tenants who pay only the BMIR rent.
For all projects except Section 236 enter:
TTP

=

(Adjusted Income / 12)

59 Field B60
(59 Field B52 / 12)

For Section 236 and Section 221(d)(3) BMIR tenants, enter:
(TR / UA)

=

(Adjusted Income / 12)

(59 Field B61 / 59 Field B54)
(59 Field B52 / 12)

For tenants whose rents are calculated on worksheets D, F, and G,
obtain this percentage from the applicable worksheet.
B65.

Police or Security
Tenant

Indicate if the tenant family has been granted the special privileges
reserved for police or security professionals in Section 8 projects. The
income limits do not apply, and the TTP must be at least 50% of
contract rent. No vacancy claim can be filed for the unit when the
police or security professional moves out.
Acceptable Values:
Y = Police or Security privileges apply to this Section 8 tenant
N or Space = No police or security privileges apply

B66.

Next Recertification
Date

Enter the date of the next scheduled annual recertification date for this
family as prescribed by Chapter 7, Section 1: Annual Recertification of
HUD Handbook 4350.3.

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Section B. Basic Record
59
Field

Field Name

Definition

B67.

Bedroom Count

Enter the number of bedrooms in the unit. (See Chapter 3, Section 2 of
HUD Handbook 4350.3 for guidance on occupancy standards and how
many bedrooms a family may have.)

B68.

Building ID

[Future Field.]

B69.

Unit Number

If each unit number is used only once within a project, enter unit
numbers (e.g., 201, 402). If a unit number is used more than once
within a project, use a unique method to identify each unit. Each
building could perhaps be given a letter or an additional number before
the unit number. Do not use a street address.

B70.

Security Deposit

A payment required by an owner to be held during the term of the lease
(or the time period the tenant occupies the unit) to offset damages
incurred due to the actions of the tenant. Such damages may include
physical damage to the property, theft of property, and failure to pay
back rent.
See Chapter 6, Section 2 of HUD Handbook 4350.3 for more
information on security deposits.

B71.

Region Code

The 2-character code for the Area associated with this certified
household. [Future Field.]

B72.

Field Office Code

Refer to the HUD Area/State Office codes.
Enter the number assigned to the HUD Field Office in which the project
is located. [Future Field.]

B73.

Tenant Signed Date

The Family head and any spouse or co-head must sign and date
(mmddyyyy) a 50059 certification generated by the owner's automated
system, as provided by Chapter 9, Section 1 of HUD Handbook 4350.3.
If the individuals sign the 50059 certification on different dates, use the
earlier date for transmission to TRACS.

B74.

Owner Signed Date

The owner, or his or her representative, must sign and date
(mmddyyyy) a 50059 certification generated by the owner's automated
system, as provided by Chapter 9, Section 1 of HUD Handbook 4350.3.

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Appendix 7

Section B. Basic Record
59
Field
B75.

Field Name
Household Assistance
Status Codes

Definition
This field relates to HUD's restrictions on assistance to noncitizens.
Enter one of the codes listed below. Consult with paragraph 3-12 and
the Glossary for the definitions of terms used in this field and for
guidance in determining which code to use.
N = Subsidy type is NOT subject to Restrictions on Assistance to
Noncitizens.
F = Verification of eligibility is pending. A family in this status is
awaiting verification of eligibility and receives full assistance.
E = All members of the family are eligible for assistance.
C = This mixed family, resident on/before June 19, 1995, qualifies for
continuation of full assistance.
P = This family qualifies for and receives prorated assistance.
T = This family is NOT eligible for assistance or this family elects
temporary deferral of termination status. Families for which this code
applies receive a temporary deferral of termination.

B76.

Family Addition
Adoption

The number of expected adopted family members. [Future Field.]

B77.

Family Addition
Pregnancy

The number of expected family additions by childbirth. [Future Field.]

B78.

Family Addition Foster
Children

The number of expected foster children as family additions. [Future
Field.]

B79.

Child Care Expense A
(Expenses that enable
a family member to
work)

Enter the amount of Child Care expense used to enable the family
member to work. This amount cannot exceed the total amount of
employment income (codes M, W, F, and B in 59 Field D2, Income
Source) that is derived because the child care is available. This
income, which is reported in 59 Field D3, Income Amount, is coded with
a "C" in 59 Field C14, Care Codes.
NOTE: See paragraph 5-10 B; For full-time students who pay for child
care while they work, the maximum child care allowance is $480.

B80.

Child Care Expenses
B (Expenses that
enable a family
member to look for
work or to attend
school)

Enter the amount of child care expense used to enable the family
member to look for work or attend school.

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4350.3 REV-1

Section B. Basic Record
59
Field
B81.

Field Name
Voucher Date

Definition
Enter the month and year for which the regular tenant assistance
payments are requested. Enter mmyyyy. Example: 012001. This is
the date that appears in Field 10 of the Form HUD-52670, Housing
Owner's Certification and Application for Housing Assistance
Payments. Complete this 59 Field B81 (Voucher Date) for all
transactions except for prevalidations and address loads (future
implementation). See Appendix 9 of HUD Handbook 4350.3 for
further information.
NOTE: This field does not apply to transactions where the subsidy
type in 59 Field A2 of the 50059 data requirements is either 4 or 5
[Section 236 or Section 221(d)(3) BMIR only, where there is no
assistance contract.]

B82.

Secondary Subsidy
Type

This applies to non-citizens who live in a Section 236 project, receive
Rent Supplement, RAP, or Section 8 assistance, and receive prorated
benefits. Valid value are “s” = for this household; or “space” = for a
household which does not live in a Section 236 project
NOTE: Space = Blank

B83.

Survivor Indicator

Indicates that the current head of household does not meet the special
conditions to qualify for the unit, but does qualify as the survivor of the
person who originally met the special requirements and qualified for the
unit.
Valid value is:
“Y” = Yes

B84.

Waiver Type Code

[Future Field.]

B85.

Move-Into Unit Date
(Family)

Enter the date the family moved into this project. This is the original
date the family moved into the project, not this unit. [Future Field.]

B86.

Owner Preference
Code

Preference codes (excluding Federal Preference Codes) indicate local
preference codes (if applicable).

B87.

Baseline Certification
Indicator

This indicator is valued with “Y” when establishing a family in TRACS
with an AR, IR, Move In, or Initial Certification. A Correction can be a
baseline. Without the baseline indicator, tenants can only be
established in the TRACS database with an MI, IC, or Correction. The
Transaction Effective Date of the Baseline Certification must be within
13 months of the current date.

B88.

Plan of Action
Indicator

This indicator is valued with “2” or “6” if the project is either Title II or
Title VI. This indicator will be used to modify the Section 8 edit to
accept Plan of Action computations. This indicator is valued with:
2 = if the project is under Plan of Action Title II.
6 = if the project is under Plan of Action Title VI.

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Appendix 7

Section B. Basic Record
59
Field

Field Name

Definition

B89.

HUD-Owned Indicator

This indicator is valued with “Y” if the project is HUD-owned. This
indicator will permit HUD-owned projects to submit certifications to
TRACS.

B90.

Unit Transfer Code

The values are:
Space = Not a Unit Transfer
Y = Unit Transfer
NOTE: If the unit number in a (re)certification is not the same as
the (re)certification it supersedes, and the unit transfer indicator is
not ‘Y,’ the (re)certification will be rejected.
Neither the project number nor the contract number can change with a
unit transfer. If either attribute changes, effect the transfer by moving
the tenant out of his or her previous unit and use an Initial Certification
to establish the tenant in his or her new unit.
A MAT70 should be submitted for a unit transfer where the tenant is not
to be recertified.

B91.

Previous Unit Number

The previous unit number is required if the (re)certification includes a
unit transfer.

B92.

Mobility Impaired

Family is mobility impaired:
Y = Yes
N = No

B93.

Hearing Impaired

Family is hearing impaired:
Y = Yes
N = No

B94.

Visually Impaired

Family is visually impaired:
Y = Yes
N = No

B95.

Tenant Unable to Sign
Indicator

The tenant is legitimately unable to sign the 50059 in time to achieve
an on-time recertification. Submit a correction with the Tenant Signed
Date (59 Field B73) populated when the tenant is able to sign.
Y = Yes (Tenant signed date = null date)
N = No (Tenant signed date populated with a legitimate date)

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4350.3 REV-1

Section C. Household (Family) Record
59
Field

Field Name

Definition

C1.

Member Number

The head of household must have a member number of “01.” Also, 59
Field C5, Relationship Code, must be coded “H.” No other family
records for the household may contain these codes. Assign a member
number to each family member. These member numbers will be used
to associate income to specific family members. Zeros (00) are not
valid.

C2.

Last Name

C3.

First Name

List the names (last name, first name, middle initial) of each person
who lives in the unit, including persons with the following codes in 59
Field C5, Relationship Code: F and L.

C4.

Middle Initial

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Appendix 7

Section C. Household (Family) Record
59
Field
C5.

Field Name
Relationship Code

Definition
List persons living in the unit in the following order and state each
person's relationship to the head by using one of the codes listed
below. See Chapter 3 of HUD Handbook 4350.3 concerning the
eligibility of families to assisted housing. Only the following codes may
be entered.
H - Head (There can be only one head. If there is a spouse or co-head,
list the same person as head on each recertification, as long as that
person resides in the household. List the other person as spouse or cohead on each recertification.)
S - Spouse (There either can be a spouse or co-head, but not both.)
K - Co-head (See paragraph 5-6 A for guidance on how to count
emancipated minors.) For the Section 202/8, Section 202 PAC, and
Section 202 PRAC and Section 811 PRAC projects, to qualify for
admission/assistance, persons must be age 62 or, if disabled, at least
18 years old. Therefore, a head, spouse or co-head under the age of
18 would not occur in these programs.
D - Dependent. See paragraph 5-6 A of HUD Handbook 4350.3.
Count any member of the family currently living in the unit who is:
-Age 17 or younger.
-18 or older and disabled or a full-time student.
-Child temporarily absent due to placement in a foster home.
-Child who is subject to joint custody agreement (lives in unit at
least 50% of time).
-Full-time student (regardless of age) away at school but lives
with family during school breaks.
-Child being adopted (or custody being sought) and currently
living in unit.
O - Other adult member of the family who is not the head, spouse or
co-head and whose income is counted in determining the family's
annual income. See paragraph 5-6. This member's status cannot be
used to justify the family's eligibility for the elderly or medical
allowances.
F - Foster child under the age of 18 or child of a foster child. See
paragraph 5-6 A. The income of a child in this category is not counted
in determining the family's annual income; the child does not qualify the
family for a dependent allowance nor are medical or handicap
assistance expenses considered for children in this category.
However, child care expenses for children in this category who are
under the age of 13 are considered under the child.

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Section C. Household (Family) Record
59
Field
C5.

Field Name

Definition

Relationship Code –
continued

L - Others Living in the Unit Who are not Members of the Tenant
Family. See paragraph 5-6. Include, but not limited to foster adults,
and live-in aides. See the regulatory definitions of these terms in the
Glossary in HUD Handbook 4350.3. See also paragraph 3.6 E for
guidance on live-in attendants. Persons in this category do not have
rights under the lease. Persons in this category are not considered
members of the family and their income is not counted in determining
the family's annual income.

C6.

Sex Code

For each person listed, enter "F" for female or "M" for male. Leave
blank for unborn children and minors being pursued for adoption or
legal custody who are not yet residents of the unit, even if the sex is
known.

C7.

Birth Date

Enter month, day, and year for each person listed using the following
format – mmddyyyy. Do not complete for unborn children or persons
under the age of 18 who are being pursued for custody or adoption who
do not yet live in the unit.

C8.

Special Status Code

Completion of this field will help to indicate adjustments to annual
income which the family is entitled to receive. In the future, this field
will also provide information on elderly tenants who are frail.

(Cont.)

Enter any of the codes listed below which apply to family members
identified in 59 Field C5 (Relationship Code) as H, S, K, D, and O.
Enter all codes below which apply. (See HUD Handbook 4350.3,
Glossary, for the definitions of the terms "Elderly Family," “Elderly
Person,” "Disabled Family,” and “Disabled Household.”)
E = Elderly Head, Spouse, Co-head (individual is at least 62 years old)
as of the effective date of this certification. (Such individual must have
one of the following codes in 59 Field C5: H, S, or K.)
S = Full-time student who is at least 18 years old as of the effective
date of this certification and who is not the Head, Spouse, Co-head.
(Such individual must have been identified in 59 Field C5 with Code D.)
H = Family Member who is disabled. (Such individual must have been
identified in 59 Field C5 with one of the following codes: H, S, K, or D.)
F = Frail Elderly [Future Field.]
J = Dependent whose custody is jointly shared by more than one
family.

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Appendix 7: The 50059 Data Requirements

4350.3 REV-1

Appendix 7

Section C. Household (Family) Record
59
Field
C9.

Field Name
Identification Code

Definition
SSN or TRACS ID Number. Enter the 9-digit social security number of
family members who are 6 years of age and older. Regulations do not
require owners to enter social security numbers for children under six
years of age; however, social security numbers should be entered if
available. Do not use dashes. If the family member does not have a
social security number, enter 999999999 in this field the first time
information for this family is submitted. A TRACS Tenant ID number
will be generated by the TRACS system and owners will be notified of
the numbers. This number should be entered on each subsequent
submission until a social security number is reported.
Do not include social security numbers for persons who are not family
members (i.e., live-in attendants, foster children, and foster adults.
TRACS will assign a Tenant ID number for these individuals.)

C10.

Member Eligibility
Code

Enter one of the following codes for each person listed in 59 Field C2C8 (list of all persons residing in the unit). Consult with paragraph 3-12
and the Glossary on what the terms below mean. Obtain the
information about each individual by reviewing the tenant/applicant
declaration:
EC = individual is a citizen or national
EN = individual is a noncitizen with eligible immigration status
IC = Ineligible noncitizen child of a family head or spouse
(NOTE: A co-head does not qualify for continued assistance.)
IN = Member is an ineligible noncitizen
IP = Ineligible parent of a head of household or spouse
(NOTE: A co-head is not eligible for continued assistance.)
PV = individual's eligibility status is pending verification
XX = individuals who are not counted as members of the family (i.e.,
foster children, live-in attendants, foster adults). 59 Field C5 shows a
relationship code of "F" or "L" for these individuals.

C11.

Alien Registration
Number

Enter the Alien Registration Number for each member of the family
provided on the applicant or tenant declaration made regarding eligible
immigration status. Do not enter dashes.

C12.

Occupation
Description

[Future Field.]

C13.

Able to Work Care
Code

Assistance provided so a household member can work.
Valid codes are:
C = Child Care
H = Handicapped (This field includes disabled.)
CH = Both

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Appendix 7: The 50059 Data Requirements

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Appendix 7

4350.3 REV-1

Section C. Household (Family) Record
59
Field
C14.

Field Name
Care Codes

Definition
Complete this field only if the family incurs child care or disability
expenses that enable an adult family member to work. Consult with
paragraph 5-10 of HUD Handbook 4350.3 on what expenses to count.
Enter the code next to the income of the adult who is able to work as a
result of the expense.
C = An adult who is able to work because child care is available.
H = Each adult who is able to work because handicapped assistance is
available. [This field includes disabled.]
CH = Each adult who is able to work because both child care and
handicap assistance is available.
The following income types in 59 Field D2 can be used to determine
the employment ceiling for child care and handicap care allowances:
M, F, W, and B.
EXAMPLE: Ms. Wright works two jobs (Nonfederal wages – W),
earning $10,000 and $4,000 respectively. She pays for child care for
the first job only. The owner would enter C by the $10,000 amount but
not by the second amount.

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HUD Occupancy Handbook
Appendix 7: The 50059 Data Requirements

4350.3 REV-1

Appendix 7

Section D. Income Record
59
Field

Field Name

Definition

D1.

Member Number

Numeric starting with “01” for the Head of Household. The member
number in the income record must be the same as the Member
Number in the MAT10, Section 3 Family Record for the family
member associated with the income record. Zeros (00) are not valid.

D2.

Code (Income Type)

Enter each source of income separately for each family member.
Attribute the source to family members using the Member Number
from 59 Field C9, Identification Code. Enter the source of the income
using the following codes:
PE = Pensions (including veterans pensions, military retirement, and
income from all other pensions and annuities)
T = TANF (Temporary Assistance for Needy Families)
SS = Social Security
G = General Assistance
SI = Supplemental Security Income (SSI)
CS = Child Support
M = Military Pay
F = Federal Wage
W = Nonfederal Wage (including salaries, tips, commission bonuses,
and other income from employment)
U = Unemployment
I = Indian Trust
B = Business (including distributed profits and net income from
business)
N = Other Nonwage Source (including alimony, unemployment
benefits)
EXAMPLE: Member 01 works three nonfederal jobs, paying $10,000,
$4,000, and $2,000, respectively. Enter each source of income
separately and attribute Code W, Nonfederal Wage, to each: W $10,000; W - $4,000; and W - $2,000.

D3.

Amount (Income)

Enter the amount anticipated to be received during the 12-month
period following the Transaction Effective Date for each family
member in accordance with paragraph 5-5 of HUD Handbook 4350.3.
Do not include income from assets.

HUD Occupancy Handbook
Appendix 7: The 50059 Data Requirements

29

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Appendix 7

4350.3 REV-1

Section D. Income Record
59
Field
D4.

Field Name
New Household
Member Income
Indicator

Definition
A new income-producing member to this household who was not on a
previous 50059 or who was not producing income on the previous
50059.
Valid values are:
Y = New income member
N = Not a new income member
Space = Not applicable
[Future Field.]

D5.

Newly Employed
Income Indicator

A member of a household who was unemployed on previous 50059
but is now employed on this 50059.
“Y” = Newly employed
“N” = Still unemployed
Space = Not applicable
[Future Field.]

D6.

SSN Benefits Claim
Number

Enter the social security claim number under which a family member
receives income benefits only if it is different from that member's own
number. NOTE: Enter the alpha/numeric suffix attached to the end of
the social security claim number. Do not enter dashes.
[Future Field]

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HUD Occupancy Handbook
Appendix 7: The 50059 Data Requirements

4350.3 REV-1

Appendix 7

Section E. Asset Record
59
Field

Field Name

Definition

E1.

Member Number

Numeric starting with “01” for the Head of Household. The member
number in the asset record must be the same as the Member Number
in the MAT10, Section 3 Family Record for the family member
associated with the asset record. Zeros (00) are not valid.

E2.

Description

List the type of each asset now owned and each asset disposed of for
less than fair market value in the two years preceding the date in 59
Field B9, Transaction Effective Date. Examples: "checking account";
"savings account"; "IRA"; "Stamp collection.”

E3.

Status

Classify each asset entered in 59 Field E2 as follows:
Enter C (for current), for an asset that the household currently owns.
Enter I (for imputed), for any asset the family has disposed of that
must still be counted in accordance with HUD Handbook 4350.3. An
imputed value is used for these assets, since they have already been
disposed of and there is no actual income.

E4.

Cash Value Amount

Enter the cash value of each asset listed in 59 Field E2, Description
(Asset). Refer to paragraph 5-7 C on valuing assets.

E5.

Actual Yearly Income
Amount

For each asset identified in 59 Field E2, enter the actual yearly
income anticipated to be received by the family.

E6.

Date Divested

MMDDYYYY. The date the family disposed of the asset.

HUD Occupancy Handbook
Appendix 7: The 50059 Data Requirements

31

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Appendix 8
50059 Data Entry Rules

Appendix 8

4350.3 REV-1

Appendix 8: 50059 Data Entry Rules
Appendix 8 provides:

1.

•

Data entry rules for the 50059 data requirements;

•

Examples of rounding; and

•

Data entry rules for TRACS transmissions.

Data Entry Rules for the 50059 Data Requirements
A.

Round up at $0.50. This procedure is consistent with the data entry instructions
for TRACS.
Example – Rounding Procedures
Amount

B.

Rounded Amount

$49.49

$49.00

$49.50

$50.00

Carry decimals from one step to another on calculations made before a TRACS
entry is made.
Each calculation in the following examples is performed prior to the TRACS
submission. Therefore, actual numbers are used in each calculation.

2.

Examples of Rounding
A.

In computing an individual tenant's income, an hourly wage should be computed
as follows:
$5.11/hour x 33.25 hours per week x 52 weeks
$5.11 x 33.25 = $169.9075 = $169.91
$169.91 x 52 = $8,835.32
Note that the owner carried the decimals from one step to the next because
these are pre-TRACS calculations. The owner will go on to enter $8,835 as the
income for this individual into the 50059 data requirements, which will then be
transmitted to TRACS. See the discussion below on TRACS data-entry
requirements.

HUD Occupancy Handbook
Appendix 8: 50059 Data Entry Rules

1

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4350.3 REV-1

B.

Appendix 8

A family has the following assets: $1,331.49 (Savings); $4,322.50 (IRA);
$3,255.50 (cash value of life insurance). The owner will round each asset to the
nearest dollar and enter the rounded amounts into the 50059 data requirements,
which will then be transmitted to TRACS.
$ 1,331 Savings
$ 4,323 IRAs
$ 3,256 Life Insurance
$ 8,910 Total Cash Value of All Assets

C.

In calculating amounts for adjustments such as Total Medical Expenses, each
expense should be calculated and rounded to the nearest $0.01. The expenses
to the $0.01 are added together to produce a total that is then rounded to the
nearest dollar.
$33.66

Prescription

$236.00 Doctor’s visit
$269.66 Total
Enter $270 in the 50059 data requirements.
3.

Data Entry Rules for TRACS Transmissions
Owners and software vendors must follow the instructions included in the MAT Guide
regarding data entry for TRACS transmissions (e.g., right/left justifications, number of
fields, field length, etc.).

5/03

•

Only whole numbers may be transmitted to TRACS.

•

When rounding, dollar amounts must be rounded down at $0.49 and up at
$0.50.

•

Do not carry decimals through several transactions once a TRACS entry
has been made.

2

HUD Occupancy Handbook
Appendix 8: 50059 Data Entry Rules

Appendix 8

4350.3 REV-1

Example
Family Member

Actual Amount

Reported to TRACS

1

$ 7,655.49

$ 7,655

2

$ 8,400.50

$ 8,401

3

$ 3,900.47

$ 3,900

$ 19,956.20

$ 19,956

In this example, each individual member's actual earned income, rounded to a
whole number, is submitted to TRACS.

Example – When Computing TTP in MAT 10, Field 64 of the 50059 Data
Requirements
Annual income in the following example had already been determined and entered as a record
in the TRACS submission. Therefore, it is already a rounded number. (NOTE: These are
only a sample of the calculations used to determine TTP.)
ƒ

Annual Adjusted Income divided by 12 months = Monthly Adjusted Income
$6,525 / 12 = $543.75 ($6,525 was previously entered and is a rounded number.)

ƒ

Monthly Adjusted Income multiplied by .30
$543.75 x .30 = $163.125 = 163.13
This amount has not been entered into TRACS, so the owner would use the decimals.

ƒ

The amount that the owner enters for TTP would be the highest of the three amounts
provided in Exhibit 5-9. That amount would be rounded when it is entered into the 50059
data requirements.

NOTE: It would be incorrect for the owner to use the actual amount of annual income in this
calculation, since Annual Income has already been entered onto the 50059 data requirements.

HUD Occupancy Handbook
Appendix 8: 50059 Data Entry Rules

3

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4350.3 REV-1

Appendix 8

Example
Again, in the following example of correct rounding, the individual income amounts are rounded
because they are transmitted to TRACS. A member of a household had the following earned
income:
Family Member

Actual Earned Income

Amount Entered in the Data Requirements
and Submitted to TRACS

1

$ 3,298.46

$ 3,298 *

1

$ 5,024.49

$ 5,024

1

$ 1,655.50

$ 1,656

1

$ 9,977.99

$ 9,978

*The amounts submitted to TRACS are rounded.
NOTE: Prior to 9/95, if an individual had multiple income sources for one type of income (e.g.,
wages), the owner entered the total amount. Now, the owner enters each income source for a type
of income. Since each source of income is listed on the 50059 data requirements and then
transmitted to TRACS, each entry must be rounded.

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HUD Occupancy Handbook
Appendix 8: 50059 Data Entry Rules

Appendix 9
Form HUD-52670, Housing Owner’s
Certification and Application for Housing
Assistance Payments

Appendix 9

4350.3 REV-1

The Form HUD-5260 has been revised and is awaiting OMB approval. Continue to use the
current HUD-52670 and the current instructions until the revised form is available. The current
HUD-52670 is available on HUDCLIPS.

HUD Occupancy Handbook
Appendix 9: Housing Owner’s Certification
and Application for Housing Assistance
Payments and Instructions for Preparing HUD-52670

1

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Appendix 9

4350.3 REV-1

Appendix 9: Housing Owner’s Certification and Application For Housing
Assistance Payments and Instructions for Preparing form HUD-52670
GENERAL:
A.

Prepare a separate form HUD-52670 for each subsidy contract for each of the
following:
1.

Regular tenant assistance payments, adjustments, and approved special
claims: unpaid rents, damages and other charges, and vacancies.

2.

Approved debt service claims.

B.

Request payment of special claims after forms HUD-52670-A part 2, and HUD52671-A through D, as applicable, are approved by the HUD Field Office or
Contract Administrator. More complete instructions on special claims processing
and payment are in HUD’s Special Claims Processing Guide.

C.

Neither HUD nor the Contract Administrator will pay special claims unless
approval numbers are included.
NOTE: Do not submit Special Claims forms HUD-52671-A through D and
supporting documentation to HUD or Contract Administrator when requesting
payment for unpaid rent, damages and other charges, vacancies, or debt service.
THESE FORMS AND DOCUMENTATION ARE REVIEWED AND APPROVED
PRIOR TO REQUESTING PAYMENT.

TIMING OF BILLINGS:
A.

RENT SUPPLEMENT AND RAP TENANTS: Submit billing forms by the 10th
day of the month for which payments are requested.

B.

SECTION 8, PAC AND PRAC TENANTS: Submit billing forms by the 10th day
of the month before the month for which they are requested.
EXAMPLE: To request assistance for June, owners must submit vouchers by
June 10 for PRAC, Rent Supplement, and RAP tenants, or May 10 for Section 8
and PAC tenants.

Part I. Contract Information
ITEM 1. PROJECT NAME. Enter the name as it appears on the subsidy contract.
(Abbreviated project name resulting from the use of software is acceptable.)
ITEM 2. FHA/EH/NONINSURED PROJECT NUMBER. Mandatory for Section 236, Section
221(d)(3) BMIR, Rent Supplement, RAP, PAC, and PRAC subsidy types. Requested
5/03

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HUD Occupancy Handbook
and Application for Housing Assistance
Payments and Instructions for Preparing HUD-52670

Appendix 9

4350.3 REV-1

for those Section 8 contracts for which a FHA project number applies.
NOTE: Do not use “0000FMHA” as a project number in RHS Section 515 projects.
Do not enter a project number for RHS Section 515 projects.
Sample entries are provided below.
FHA Insured
Projects

Elderly Housing
Projects

Other Noninsured
Projects

12144026

121EH001

121001NI

ITEM 3. SECTION 8/PAC/PRAC CONTRACT NUMBER. Mandatory for Section 8, Section
202 PAC, Section 202 PRAC, and Section 811 PRAC subsidy types.
ITEM 4. TYPE OF SUBSIDY. If you are using software, enter "1" for Section 8, enter "2" for
Rent Supplement, enter "3" for Rental Assistance, enter “7” for Section 202 PRAC,
enter “8” for Section 811 PRAC, or enter “9” for Section 202 PAC. CHECK ONLY
ONE BOX.
ITEM 5a. MANAGEMENT AGENT NAME. Enter the agent's company name.
ITEM 5b. EMPLOYER IDENTIFICATION NUMBER (EIN).

Part II. Occupancy and Income Eligibility Information
ITEM 6. GENERAL OCCUPANCY INFORMATION. Consider only those units under this
subsidy contract when completing ITEMS 6a through 6e.
A.

Complete this item if you are requesting regular tenant assistance payments for
Section 8, RAP, Rent Supplement, and PAC tenants (see B below for PRAC
instructions). Do not complete for debt service claims.
1.

TOTAL UNITS IN CONTRACT. Do not include HUD-approved,
nonrevenue producing units.

2.

NUMBER OF UNITS RECEIVING SUBSIDY.
a.

Include tenants who are receiving Section 8, Rent Supplement,
RAP, or PAC assistance.

b.

Do not include tenants who are terminated from assistance.

3.

NUMBER OF TIMES ABATED. Indicate the number of units in 6a for
which assistance cannot be paid due to natural disaster or health and
safety reasons.

4.

NUMBER OF UNITS VACANT. Indicate how many units in 6a are
vacant.

HUD Occupancy Handbook
Appendix 9: Housing Owner’s Certification
and Application for Housing Assistance
Payments and Instructions for Preparing HUD-52670

3

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Appendix 9

4350.3 REV-1

5.

NUMBER OF UNITS IN 6A THAT ARE OCCUPIED BY MARKET-RATE
TENANTS. Include tenants being charged market rent.
CHECKPOINT:

B.

6a must equal the sum of 6b + 6c + 6d + 6e.

Section 202 PRAC and Section 811 PRAC Contracts. Complete only:
6a. TOTAL UNITS IN CONTRACT. Do not include HUD-approved,
nonrevenue producing units; and
6c. NUMBER OF UNITS VACANT. Indicate how many units in 6a are
vacant.

ITEM 7. EXCEPTIONS TO LIMITATIONS ON ADMISSION OF LOW-INCOME
FAMILIES.
Complete if the contract is Section 8 and was effective on or after 10/1/81, and if
regular tenant assistance payments are being requested.
A.

PROJECT-BASED EXCEPTIONS IN USE. Obtain from column 12 of form HUD52670-A part 1, Schedule of Tenant Assistance Payments Due, by counting all
EP codes.

B.

PROJECT-BASED EXCEPTIONS ALLOCATED. Enter the number of
exceptions the HUD Field Office has:
1.

Approved for situations 2 through 6 of 4350.3, Exhibit 3-1; and

2.

NOT taken back.

C.

TENANT-BASED EXCEPTIONS IN USE. Obtain from column 12 of form HUD52670-A part 1, Schedule of Tenant Assistance Payments Due, by counting all
codes that begin with an "E" and end with "T".

D.

TOTAL EXCEPTIONS. Add 7b and 7c.

E.

PROJECT-BASED EXCEPTIONS – DATE LAST CHANGED. Enter the date of
the last HUD letter that increased or decreased the number of exceptions
allocated to this project. Leave space blank if HUD has never given this contract
any project-based exceptions.

Part III. Breakdown of Assistance Payment Requested
ITEM 8a. MONTH/YEAR. Enter the month and year for which the assistance is requested.
ITEM 9. NUMBER OF UNITS INCLUDED IN BILLING. Enter the number of contract units for
which each type of payment is requested.
ITEM 10. AMOUNT REQUESTED. These amounts are from form HUD-52670-A part 1,
Schedule of Tenant Assistance Payments Due, and the approved form HUD-52670-A
part 2, Schedule of Special Claims.
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HUD Occupancy Handbook
and Application for Housing Assistance
Payments and Instructions for Preparing HUD-52670

Appendix 9

4350.3 REV-1

If a schedule has more than one page, enter the total of all pages on the schedule.
TYPE OF ASSISTANCE

ADD ALL AMOUNTS IN:

a. Regular Tenant Assistance Payments
b. Adjustments to Regular Tenant
Assistance Payments
c. Special Claims

Item 17a of Part 1
Item 17b of Part 1

i. Unpaid Rent
ii. Tenant Damages
iii. Vacancies

Column 3 of Part 2
Column 4 of Part 2

1) Rent-Up Vacancies
2) Regular Vacancies

Column 5 of Part 2
Column 6 of Part 2

iv. Debt Service

Column 7 of Part 2

e. Total Subsidy Authorized Under
Rules in Handbook 4350.3

(Total of all amounts in Part
III, Column 10, of this form)

ITEM 11. AMOUNT APPROVED. This column is for HUD/Contract Administrator use only.
LEAVE BLANK.

Part IV. Distribution of Subsidy Earned
The total amount approved for payment by HUD or the Contract Administrator is reflected on
line 11e. Monthly assistance payment amounts are electronically transferred to the project
account authorized on the owner’s submission of Form 1199. Owners wishing to change
deposit instructions must send a new Form 1199 to HUD prior to making the account change.

Part V. Owner’s Certification
Printed name of owner/agent, signature of owner/agent, and telephone number including area
code.
Submission Requirements.
The form HUD-52670 must be electronically submitted to TRACS monthly using MAT 30 to
receive payment. Owners who have a Contract Administrator are required to electronically
submit the form HUD-52670 to the Contract Administrator for approval and payment. The
Contract Administrator is responsible for transmitting a correct form HUD-52670 to TRACS.
HUD or the Contract Administrator will review the form HUD-52670 and may request
submission of the form HUD-52670-A part 1, Schedule of Tenant Assistance Payments Due, to
HUD Occupancy Handbook
Appendix 9: Housing Owner’s Certification
and Application for Housing Assistance
Payments and Instructions for Preparing HUD-52670

5

5/03

Appendix 9

4350.3 REV-1

verify the requested assistance payment amounts against tenant data submitted to TRACS for
the project.
Form HUD-52670 submissions that include requests for Special Claims must be accompanied
by form HUD-52670-A part 2, Schedule of Special Claims, containing approved amounts of
special claims with their assigned numbers.

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6

HUD Occupancy Handbook
and Application for Housing Assistance
Payments and Instructions for Preparing HUD-52670

U.S. Department of Housing
and Urban Development
Office of Housing
Federal Housing Commissioner

Housing Owner's Certification
and Application for Housing
Assistance Payments

OMB Approval No. 2502-0182 (11/30/2003)

Part I - Contract Information

HUD Use Only

1. Project Name :

2. FHA / EH / Non-Insured No. 3. Section 8 Contract Number:

4. Type of Subsidy (one only):

Sec. 8
Rent Supp.
RAP

5a. Management Agent's Name:

Voucher Number:

6. Payee's address; or bank address & account number; or
ABA (American Banking Association) route & account no.

Date Received :

Date Paid :
5b. EIN :

Part II - Occupancy & Income Eligibility Information
8. Exceptions to Limitations on Admission of Lower-Income Families
(only for Sec. 8 contracts effective on or after 10/1/81):

7. General Occupancy Information (contract specific):
a. Total Units in contract

a. Project-based exceptions in use

b. Number of Units receiving

b. Project-based exceptions allocated

subsidy under this contract
c. Number of Units vacant

Enter the number of units now leased to
lower-income families who:
1. began receiving Section 8 on or after
8/1/84; and
2. were not very low income at the time
they began to receive Section 8.

c. Tenant-based exceptions in use

under this contract

9. Tenant Income Information ( only for Sec. 8
contracts effective before 10/1/81 ):

d. Total exceptions

d. Number occupied by

0

(line b + line c)

Market Rent Tenants

Number of units:

e. Date Field Office last changed allocations

Note: 7a must equal 7b + 7c + 7d

0

for project-based exceptions (mm/dd/yy)

Part III - Breakdown of Assistance Payment Requested

HUD Use Only
11. Number of
Units in Billing

10. Type of Assistance

12.
Amount Requested

13a.
Amount Approved

13b.
Accounting Code

1. Regular Tenant Assistance Payments for (mo./yr.):
2. Adjustments to Regular Tenant Assistance Payments
3. a. Section 8 Special Claims for Unpaid Rent
b. Section 8 Special Claims for Tenant Damages
c. Section 8 Special Claims for Vacancies
d. Section 8 Special Claims for Debt Service
4. 1983 HURRA Rent Rebates
5.

123456789012
123456789012
123456789012
Total Subsidy Authorized under instructions in Handbook 4350.3 123456789012
123456789012
123456789012

0

Part V - Owner's Certification I certify that: (1) Each tenant’s Part IV - Distribution of Subsidy Earned (HUD Use Only)

eligibility and assistance payment was computed in accordance
with HUD’s regulations, administrative procedures, and the
Contract, and are payable under the Contract; (2) all required
inspections have been completed; (3) the units for which assistance is billed are decent, safe, sanitary, and occupied or
available for occupancy; (4) no amount included on this bill has
been previously billed or paid; (5) all the facts and data on which
this request for payment is based are true and correct; and (6)
I have not received and will not receive any payments or other
consideration from the tenant or any public or private source for
the unit beyond that authorized in the assistance contract or the
lease, except as permitted by HUD. Upon request by the
Department of Housing and Urban Development, its duly authorized representative, or the Comptroller General of the United
States, I will make available for audit all books, records and
documents related to tenants’ eligibility for, and the amount of,
assistance payments. Warning: HUD will prosecute false claims
& statements. Conviction may result in criminal and/or civil penalties
(18 U.S.C. Sections 1001, 1010, 1012; 31 U.S.C. Sections 3729, 3802).
Previous editions are obsolete

Amount Approved

Accounting Code

1. Applied to HUD-held mortgage
2. Applied to debts owed by mortgagor
3. Paid to Project

1234567890123456789012345678901
1234567890123456789012345678901

1234567890123456789012345678901
of the amount
1234567890123456789012345678901
in item 5, part III was released from the1234567890123456789012345678901
1234567890123456789012345678901
1234567890123456789012345678901
Residual Receipts Account.

4. $

Printed Name, Date, Title & Phone No. (include area code) & Signature :

X

Submit an Original and two copies

form HUD-52670 (11/00)
ref. Handbook 4350.3

This form is submitted monthly by owners/agents to their Contract Administrator or HUD Field Office for each subsidy contract and provides basic
information on the project, reports the number of contract units which are
occupied by eligible tenants and bills HUD for the housing assistance
payments. Section 8 projects also must report exceptions to the rule
requiring that all units be leased to families with incomes below 50 percent
of area median income.
This form must be completed so HUD can pay owners the difference
between the gross rent and the total tenant payment (housing assistance
payments) according to regulation. It is also necessary for the forms to be
completed so the owner can recoup money lost during vacancy, and money
spent to fix damaged units and cover rent when these expenses are unpaid
by the vacating tenant.
Regulations require that owners complete this form using statutory
formulas for calculating housing assistance payments, unpaid rent and
tenant damages and vacancy loss payments.
The statutes requiring the submission are S101, Housing and Urban
Development Act of 1965 (12 U.S.C. 1701s), S236(f)(2), National Housing
Act (12 U.S.C. 17152z-1), S8, United States Housing Act (42 U.S.C. 1437
f). The regulations stipulating these rules are: 24 CFR 215, 236, 813, 880,
883, 884, 885, and 886. The administrative requirements for these forms
are provided in HUD Handbook 4350.3, Chapter 6. Copies of the statutes,
regulations and administrative requirements are provided in Appendix A.
HUD does not promise confidentiality but will not disclose data on a
specific project or tenant. No questions of a sensitive nature are asked in
this form.

The Department of Housing & Urban Development is authorized to collect
this information by the U.S. Housing Act of 1937, as amended, and to request
the Employer Identification Number (EIN) by the Housing & Community
Development Act of 1987, 42 U.S.C. 3543. The owner/agent must provide all
this information including the EIN. The information provided will be used by
HUD for the following: (1) Review accuracy of funds requested by owner /
agent for tenants’ housing assistance payments and special claims payments.
(2) Review owner / agent computation of tenant assistance payment and
tenants’ rents using specific forms and formulas. (3) Evaluate the date owner/
agent re-certify assisted tenants. (4) Limit the number of Section 8 units that
may be leased to lower-income families whose incomes exceed 50% of the
area median income. (5) Restrict or prohibit the admission of tenants who are
ineligible for assistance. (6) The EIN may be cross-checked against the EIN
reported on the Management Entity Profile (form HUD-9832) or the Rent
Schedule (form HUD-92458). This cross-check will assist in identifying
inconsistencies whereby corrective action may be taken. The EIN is used as
a unique identifier. HUD may disclose this information to Federal, state, and
local agencies when relevant to civil, criminal, or regulatory investigations and
prosecutions. Otherwise, it will not be disclosed or released outside of HUD,
except as permitted or required by law. Providing all information is mandatory,
and failure to provide information will affect participation in HUD programs.
Public reporting burden for this collection of information is estimated to
average 30 minutes 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
information unless that collection displays a valid OMB control number.

form HUD-52670 (11/00)
ref. Handbook 4350.3

Appendix 10
Form HUD-52670-A Part 1, Schedule of
Tenant Assistance Payments Due

Appendix 10

4350.3 REV-1

The Form HUD-52670-A Part 1 has been revised and is awaiting OMB approval. Continue to
use the current HUD-52670 and the current instructions until the revised form is available. The
current HUD-52670-A Part 1 is available on HUDCLIPS.

HUD Occupancy Handbook
Appendix 10: Schedule of Tenant Assistance
Payments Due and Instructions for Preparing
Form HUD-52670-A Part 1

1

5/03

4350.3 REV-1

Appendix 10

Appendix 10: Schedule of Tenant Assistance Payments Due
and Instructions for Preparing form HUD-52670-A, Part 1
[These instructions apply to the 2003 updated version of this form.]
GENERAL:
A.

Prepare a separate schedule for each subsidy contract.

B.

Fill in information requested in Items 1 through 5 on the first page. If more than
one schedule is needed, complete Items 1 through 5 on subsequent pages.

Step I. Contract Information
ITEM 1. MONTH/YEAR. Enter the month/year for which the regular tenant-assistance
payments are due. COMPLETE THIS ITEM ONLY IF YOU ARE REQUESTING
REGULAR TENANT-ASSISTANCE PAYMENTS.
ITEM 2. PROJECT NAME. Enter the name as it appears on the subsidy contract.
(Abbreviated project name resulting from the use of software is acceptable.)
ITEM 3. FHA/EH/NONINSURED PROJECT NUMBER. Mandatory for Section 236, Section
221(d)(3) BMIR, Rent Supplement, RAP, PAC, and PRAC subsidy types. Required
for those Section 8 contracts for which a FHA project number applies.
NOTE: Do not use “0000FMHA” as a project number in RHS Section 515 projects.
Do not enter a project number for RHS Section 515 projects.
Sample entries are provided below.
FHA Insured
Projects

Elderly Housing
Projects

Other Noninsured
Projects

12144026

121EH001

121001NI

ITEM 4. SECTION 8/PAC/PRAC CONTRACT NUMBER. Mandatory for Section 8, Section
202 PAC, Section 202 PRAC, and Section 811 PRAC subsidy types. HUD
TRACS will use this contract number for all transactions under the Tenant Header
Record.
ITEM 5. TYPE OF SUBSIDY. If you are using software, enter “1” for Section 8, enter "2" for
Rent Supplement, enter "3" for Rental Assistance, enter “7” for Section 202 PRAC,
enter “8” for Section 811 PRAC, or enter “9” for Section 202 PRAC. CHECK ONLY
ONE BOX.
5/03

2

HUD Occupancy Handbook
Appendix 10: Schedule of Tenant Assistance
Payments Due and Instructions for Preparing
Form HUD-52670-A part 1

Appendix 10

4350.3 REV-1

Step II. Itemize Assistance Payments Requested
ITEM 6. HEAD OF HOUSEHOLD NAME, SOCIAL SECURITY NUMBER, AND DATE OF
BIRTH. Enter "last name, first initial", social security number, and date of birth.
ITEM 7. UNIT NUMBER. Enter unit numbers (i.e., 201, 402). When multiple households
share a unit, add an alpha ending to the unit number to identify the unit number by
household (i.e., 201A, 402B).
ITEM 8. UNIT SIZE. Enter the number of bedrooms in the unit.
ITEM 9. CONTRACT RENT. Enter the rent that HUD or the Contract Administrator has
approved for this unit. The Contract Rent Amount is the Section 8/RAP/PAC contract
rent, the Section 236 basic rent, the Section 221(d)(3) BMIR rent, or the Rent
Supplement unit rent, as applicable. Obtain this amount from the project’s signed
rental schedule (form HUD-92458) or subsidy contract. When multiple households
share a unit, calculate the contract rent amount as explained in Chapter 5, Paragraph
5-28.
For Section 202 PRAC and Section 811 PRAC projects, if the tenant pays utilities
separately, enter the operating rent (operating cost) minus the HUD-approved utility
allowances. If all utilities are included in the rent, enter the operating rent.
ITEM 10. UTILITY ALLOWANCE. If all utilities are included in the rent, enter 0. Otherwise,
enter the amount HUD or the Contract Administrator has approved for this unit type.
This amount can be obtained from the project’s Rental Schedule (form HUD-2458) or
subsidy contract.
ITEM 11. GROSS RENT. Enter the total of Item 9, Contract Rent, and Item 10, Utility
Allowance. When multiple households share a unit, calculate the gross rent
amount as explained in Chapter 5, Paragraph 5-28.
ITEM 12. INCOME CODE. Follow these instructions ONLY for Section 8 contracts. Complete
this item only in the regular tenant assistance part of the Schedule. Follow the
instructions in EITHER paragraph A or paragraph B below.
A.

HAP CONTRACT EFFECTIVE BEFORE 10/1/81
1.

If the tenant was not very low-income at the time he/she began to receive
Section 8, enter "LI" in Column 12. Enter this code every month for as
long as the tenant continuously receives Section 8 at this project. Enter
this code even if the tenant becomes very low-income.

2.

Otherwise, leave Column 12 blank.

HUD Occupancy Handbook
Appendix 10: Schedule of Tenant Assistance
Payments Due and Instructions for Preparing
Form HUD-52670-A Part 1

3

5/03

4350.3 REV-1

B.

Appendix 10

HAP CONTRACTS EFFECTIVE ON OR AFTER 10/1/81
1.

Move-Ins and Initial Certifications. If the instructions for 59 Field B42,
Income Exception Code, of the 50059 data requirements required you to
enter a code that starts with an "E", enter that code in Column 12.
Otherwise, leave Column 12 blank.

2.

Other Actions. If the tenant was admitted under an exception listed in
Chapter 3, paragraph 3-7, and Exhibit 3-1's very low-income
requirements, enter one of the following codes. The same code shall be
entered every month for as long as the tenant receives Section 8 at this
project. Enter this code even if the tenant becomes very low-income.
EDT

HUD approved an exception under Situation 1 of 4350.3,
Exhibit 3-1.

EP

Tenant was admitted under exceptions HUD approved for
Situations 3 through 6 of 4350.3, Exhibit 3-1.

EAT

The tenant or applicant was admitted to the Section 8 program
before the project received HUD's 6/29/84 memorandum AND the
tenant started receiving assistance on or after 8/1/84.

ET

None of these codes apply. Tenant's admission violated the
income eligibility rules of 4350.3, paragraph 3-6.

ITEM 13. TURNOVER DATA. Follow these instructions ONLY if you are implementing an initial
certification or reporting a move-in, move-out, or termination of assistance.
IMPORTANT:

Report move-ins and move-outs only after they have actually
happened. THIS MEANS THAT SINCE SECTION 8 IS
REQUESTED A MONTH IN ADVANCE, TURNOVER DATA FOR
MOVE-INS AND MOVE-OUTS WILL BE REPORTED A MONTH
LATER.

FOR
___

ENTER
THIS CODE IN 13a
_________

ENTER
THIS DATE IN 13b
__________

Move-in

I

Tenant moved into unit

Initial
Certification

C

Tenant began to receive
the type of assistance
checked in Item 5

Termination of
assistance

T

Last day for which tenant
will receive assistance

5/03

4

HUD Occupancy Handbook
Appendix 10: Schedule of Tenant Assistance
Payments Due and Instructions for Preparing
Form HUD-52670-A part 1

Appendix 10

4350.3 REV-1

Move-out

O

Tenant moved out of unit
(see paragraph 9-12 E of
4350.3 for guidance on
how to determine this date
for deceased tenants)
ITEM 14. RECERTIFICATION DATE. Applies only to annual recertification. Use these
instructions only for the regular tenant assistance part of the schedule.
A.

NEXT RECERTIFICATION DATE. Enter the month and year HUD procedures
require the tenant's next annual recertification to be effective. Effective dates are
explained in Chapter 7, Section 1: Annual Recertification, of HUD Handbook
4350.3. SHOW THIS DATE EVERY MONTH.

B.

DATE FIRST REMINDER NOTICE SENT. Enter the month/day on which you
first asked the tenant to submit this recertification data.
1.

Complete this column for the month in which the recertification notice was
issued and each month thereafter, until the recertification becomes
effective or assistance is terminated.

2.

DO NOT enter dates follow-up notices were sent.

ITEM 15. CHANGE CODE. Complete for the regular tenant assistance or adjustments part of
the schedule.
A.

Fill in this item ONLY if this schedule requests an amount of assistance different
than that requested last month.

B.

Explain the reason for the change by entering the appropriate code from the
chart below. Enter only ONE code. Enter the first code that applies.

CODE
_____

ACTION
______

IC

Initial Certification

AR

Annual Recertification

IR

Interim Recertification

UT

Unit Transfer

GR

Gross Rent Change

Assistance Terminated Because Tenant:
TI

TTP Equals/Exceeds Gross Rent

TC

Did not supply Citizenship or Eligible-Alien Documentation

TR

Did not recertify on time

HUD Occupancy Handbook
Appendix 10: Schedule of Tenant Assistance
Payments Due and Instructions for Preparing
Form HUD-52670-A Part 1

5

5/03

4350.3 REV-1

Appendix 10

TF

Submitted false information

Assistance Terminated Because HUD:
CE

Contract expired

EN

Contract under the Enforcement Center

HQ

Automatic termination because:
An annual certification was not completed within 15
months
or a move-out is not processed at a property before a
move-in is processed at a new property.

ITEM 16. TENANT ASSISTANCE PAYMENTS: Enter the amount of assistance requested for
each tenant in 16a.
A.

Regular tenant assistance payments
1.

For Section 8 contracts, enter the monthly assistance payments shown
on 59 Field B63 of the 50059 date requirements.

2.

For RAP and Rent Supplement contracts:
If the tenant received RAP or Rent Supplement for an entire month for the
same unit, enter the assistance payment shown on 59 Field B63 of the
50059 data requirements.
If the tenant received assistance for that unit for only part of the month,
prorate the assistance payment as follows:

B.

5/03

a.

Divide 59 Field B63, assistance payment, by the number of days
in the month.

b.

Multiply the answer above by the number of days the tenant
received RAP or Rent Supplement for that unit.

ADJUSTMENTS
1.

MOVE-INS AND MOVE-OUTS. Prorate the assistance payments as
described in paragraph 9-12 of HUD Handbook 4350.3.

2.

CORRECTIONS TO PRIOR BILLINGS. Briefly explain the reason for any
adjustment and enter the full adjustment required. Explain the reason for
the adjustment.

3.

IF YOU ARE RETURNING SUBSIDY. Put parentheses around these
requests (i.e., correcting for an overpayment).
6

HUD Occupancy Handbook
Appendix 10: Schedule of Tenant Assistance
Payments Due and Instructions for Preparing
Form HUD-52670-A part 1

Appendix 10

4350.3 REV-1

ITEM 17. TOTALS. Compute separate totals for each of the assistance payment types. Enter
those totals under Column 16a. Leave Column 16b totals blank.

Step III. Sign and Distribute the Schedule
CERTIFICATION: In the LAST box of the Schedule, print the name of owner/agent and
sign. Enter the date that you signed the form and your telephone number.
IMPORTANT: In signing, you certify that you have complied with HUD
Handbook 4350.3 procedures. HUD will prosecute false
claims and statements. Conviction may result in criminal
and/or civil penalties (18 U.S.C. Sections 1001, 1012; 31
U.S.C. Sections 3729, 3802)

HUD Occupancy Handbook
Appendix 10: Schedule of Tenant Assistance
Payments Due and Instructions for Preparing
Form HUD-52670-A Part 1

7

5/03

Schedule of
Tenant Assistance Payments Due

U.S. Department of Housing Urban Development
Office of Housing
OMB Approval No. 2502-0182 (11/30/2003)
Federal Housing Commissioner

Before completing this form, read and follow the instructions in Handbook 4350.3, Chapter 6.
See the statements on the back for information on public burden.
1. Asst. Pymts Due For (mo. & yr) :
2.Project Name :

4. Section 8 Contract Number:

3. FHA / EH / Non-Insured Project No:

5. Type of Subsidy (mark only one):

Sec.8 Housing Assistance Payments

Rent Supplement

Rental Assistance Payments

7. Section 8 Contract Information (only
only for Sec.8 projects) :

6. Type of Section 8 (mark only one) :

Substantial Rehabilitation
New Construction
Loan Management Set Aside
Property Disposition Set Aside

Yes
Yes
Yes

a. Was the HAP Agreement signed on or after 10/1/81?
b. Was the HAP Contract effective on or after 10/1/81?
c. If this is an LM/PD Set Aside (without Rehab.),

No
No
No

N/A

was the HAP Contract signed on or after 10/3/84?
Turnover Data
8.
Tenant Name (last, first)

9.
Unit Number or Address

10.
Income
Code

11a.
Code

11b.
Mo./Day

Recertification Data
12a.

12b.

Tenant Assistance Payment
13.

Scheduled Date Initial Change
Effective Notice Sent Code

14a.
Requested

14b.
Approved
HUD use only

Date

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18

Owner/Agent Certification: I hereby certify that all pages of this schedule are true
and correct and that all amounts were computed in accordance with HUD Handbook
4350.3 and any other applicable HUD instructions.

15. Totals

for this
page

a. Regular Tenant

Assistance
b. Adjustments

Printed Name, Signature, Date, Title & Phone No. (include area code) :
c. 1983 HURRA

Refund or Credit
HUD Reviewer & Date:

HUD will prosecute false claims & statements. Conviction may result in criminal and/
or civil penalties (18 U.S.C. Sections 1001, 1010, 1012; 31 U.S.C. Sections 3729, 3802).
Previous editions are obsolete

Submit an Original and two copies

Page (

) of (

)

ref. Handbook 4350.3

form HUD-52670-A part 1

(6/91)

This form must be completed so HUD can pay owners the difference between
the gross rent and the total tenant payment (housing assistance payments)
according to regulation. This information is necessary so the owner can
recoup money lost during vacancy, and money spent to fix damaged units and
cover rent when these expenses are unpaid by the vacating tenant.
Regulations require that owners complete this form using statutory formulas for calculating housing assistance payments, unpaid rent and tenant
damages and vacancy loss payments.
The statutes requiring the submission are S101, Housing and Urban
Development Act of 1965 (12 U.S.C. 1701s), S236(f)(2), National Housing Act
(12 U.S.C. 17152z-1), S8, United States Housing Act (42 U.S.C. 1437 f). The
regulations stipulating these rules are: 24 CFR 215, 236, 813, 880, 883, 884,
885, and 886. The administrative requirements for these forms are provided
in HUD Handbook 4350.3, Chapter 6. Copies of the statutes, regulations and
administrative requirements are provided in Appendix A.
HUD does not promise confidentiality but will not disclose data on a specific
project or tenant. No questions of a sensitive nature are asked in this form.

Previous editions are obsolete

The Department of Housing & Urban Development is authorized to collect this
information by the U.S. Housing Act of 1937, as amended. The owner/agent must
provide all this information. The information provided will be used by HUD for the
following: (1) Review accuracy of funds requested by owner/agent for tenants’
housing assistance payments and special claims payments. (2) Review owner/
agent computation of tenant assistance payment and tenants’ rents using
specific forms and formulas. (3) Evaluate the date owner/agent re-certify
assisted tenants. (4) Limit the number of Section 8 units that may be leased to
lower-income families whose incomes exceed 50% of the area median income.
(5) Restrict or prohibit the admission of tenants who are ineligible for assistance.
HUD may disclose this information to Federal, state, and local agencies when
relevant to civil, criminal, or regulatory investigations and prosecutions. Otherwise, it will not be disclosed or released outside of HUD, except as permitted or
required by law. Providing all information is mandatory, and failure to provide
information will affect participation in HUD programs.
Public reporting burden for this collection of information is estimated to
average 0.5 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 a person is not required to respond to, a collection
information unless that collection displays a valid OMB control number.

ref. Handbook 4350.3

form HUD-52670-A part 1

(6/91)

Appendix 11
Form HUD-52670-A Part 2, Schedule of
Section 8 Special Claims

Appendix 11

4350.3 REV-1

The Form HUD-52670-A Part 2 has been revised and is awaiting OMB approval.
Continue to use the current HUD –52670-A Part 2 until the revised form is available.
The current HUD-52670-A Part 2 is available on HUDCLIPS.

U.S. Department of Housing and
Urban Development
Office of Housing
Federal Housing Commissioner

Schedule of Section 8
Special Claims
Instructions
Follow guidelines in HUD
Handbook 4350.3, Chapter 6

Project Name

Tenant Name

(1)

OMB Approval No. 2502-0182 (11/30/2003)

FHA Project No.

Unit Number

Type and Amount of Claim ($)
Unpaid Rent
From HUD
52671-A
(3)

(2)

Section 8 Contract No.

Tenant Damages
From HUD
52671-A
(4)

Rent-Up
Vacancies
From HUD
52671-B
(5)

Regular
Vacancies
From HUD
52671-C
(6)

Debt Service
From HUD
52671-D
(7)

Totals

I certify: (a) the above amounts have been computed in accordance with all instructions HUD Field Office Review
Claim approved.
and requirements prescribed by HUD and the applicable Section 8 Contract; (b) all
Claim adjusted. Reason:
prerequisites to and conditions for the assistance claimed have been met; and (c) all
Claim denied. Reason:
required documentation will be retained in the project's files for 3 years.
Owner's printed name, signature, date, & phone no.

HUD official's name, signature, & date

HUD will prosecute false claims & statements. Conviction may result in criminal and/or civil
penalties (18 U.S.C. Sections 1001, 1010, 1012; 31 U.S.C. Sections 3729, 3802).
Submit an original and three copies

form HUD-52670-A Part 2 (6/91)
ref. Handbook 4350.3

This form must be completed so HUD can pay owners the difference between
the gross rent and the total tenant payment (housing assistance payments)
according to regulation. This information is necessary so the owner can
recoup money lost during vacancy, and money spent to fix damaged units and
cover rent when these expenses are unpaid by the vacating tenant.
Regulations require that owners complete this form using statutory formulas for calculating housing assistance payments, unpaid rent and tenant
damages and vacancy loss payments.
The statutes requiring the submission are S101, Housing and Urban
Development Act of 1965 (12 U.S.C. 1701s), S236(f)(2), National Housing Act
(12 U.S.C. 17152z-1), S8, United States Housing Act (42 U.S.C. 1437 f). The
regulations stipulating these rules are: 24 CFR 215, 236, 813, 880, 883, 884,
885, and 886. The administrative requirements for these forms are provided
in HUD Handbook 4350.3, Chapter 6. Copies of the statutes, regulations and
administrative requirements are provided in Appendix A.
HUD does not promise confidentiality but will not disclose data on a specific
project or tenant. No questions of a sensitive nature are asked in this form.

Submit an original and three copies

The Department of Housing & Urban Development is authorized to collect
this information by the U.S. Housing Act of 1937, as amended. The owner/
agent must provide all this information. The information provided will be used
by HUD for the following: (1) Review accuracy of funds requested by owner/
agent for tenants’ housing assistance payments and special claims payments.
(2) Review owner/agent computation of tenant assistance payment and
tenants’ rents using specific forms and formulas. (3) Evaluate the date owner/
agent re-certify assisted tenants. (4) Limit the number of Section 8 units that
may be leased to lower-income families whose incomes exceed 50% of the
area median income. (5) Restrict or prohibit the admission of tenants who are
ineligible for assistance. HUD may disclose this information to Federal, state,
and local agencies when relevant to civil, criminal, or regulatory investigations
and prosecutions. Otherwise, it will not be disclosed or released outside of
HUD, except as permitted or required by law. Providing all information is
mandatory, and failure to provide information will affect participation in HUD
programs.
Public reporting burden for this collection of information is estimated to
average 0.33 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
information unless that collection displays a valid OMB control number.

form HUD-52670-A Part 2 (6/91)
ref. Handbook 4350.3

Appendix 12
Special Claims Worksheets
• Form HUD-52671-A, Section 8 Special Claims
for Unpaid Rent/Damages
• Form HUD-52671-B, Section 8 Special Claims
for Vacancies During Rent-Up
• Form HUD-52671-C, Section 8 Special Claims
for Regular Vacancies
• Form HUD-52671-D, Section 8 Special Claims
for Debt Service

Appendix 12

4350.3 REV-1

The Special Claims Worksheets have been revised and are awaiting OMB approval.
Continue to use the current Forms HUD-52671-A, HUD-52671-B, HUD-52671-C and
HUD-52671-D until the revised forms are available.
The current forms are available on HUDCLIPS.

Section 8 Special Claims for
Unpaid Rent / Damages
Instructions
Follow guidelines
in HUD Handbook
4350.3, Chapter 6

U.S. Department of Housing
and Urban Development
Office of Housing
Federal Housing Commissioner

Project name

FHA project no.

Section 8 contract no.

Tenant name

Unit No.

Previous tenant's move-out date

Total amount
collected from
tenant

HUD's maximum liability

Unpaid rent claim

HUD's remaining
liability applicable to damages

OMB Approval No. 2502-0182 (11/30/2003)

1.

Enter the security deposit you collected. Warning: If you did not
collect the required security deposit from the tenant that caused this
claim, stop! You cannot file this special claim.

2.

Enter the interest you earned on the security deposit

3.

Enter the money you collected for unpaid rents & damages

4.

Total amount collected. Add lines 1-3

5.

Enter monthly contract rent at move-out date

6.

Subtract line 4 from line 5 (equals maximum HUD liability). If this
amount is 0 or negative, stop! You have exceeded HUD's maximum. You cannot file a claim for unpaid rent or damages.

7.

Enter rent charged but unpaid at move-out

8.

Subtract line 4 from line 7 (not less than 0)

9.

Enter the lesser of lines 6 & 8. Also, enter in column 3 on HUD
52670–A, Part 2.

Tenant's move-in date

10. Subtract line 9 from line 6. If this amount is 0 or negative, stop!
You have exceeded HUD's maximum. You cannot file a claim for
damages.
11. Enter cost to repair damage
12. Enter the remaining amount of the security deposit (line 4 minus line
7) This cannot be less than 0
13. Amount of damage exceeding the remaining security deposit (line 11
minus line 12) This cannot be less than 0
14. Enter the lesser of lines 10 & 13. Also, enter in column 4 on HUD
52670-A, Part 2.

I certify: (a) I collected the appropriate security deposit according to Chapter
4, Section 2, page 4-4, paragraph 4-8b(2) and (3). (b) I billed tenants for unpaid
rent or damages and took all reasonable steps to collect the debt. (c) I
determined the damage claim was due to the tenant's negligence or abuse. (d)
All documentation will be retained in the project's file for 3 years.
Owner's printed name, signature, & date

HUD Field Office Review
Claim approved.
Claim adjusted. Reason:
Claim denied. Reason:
HUD official's name, signature, & date

HUD will prosecute false claims & statements. Conviction may result in criminal and/
or civil penalties (18 U.S.C. Sections 1001, 1010, 1012; 31 U.S.C. Sections 3729, 3802).
Submit an original and two copies

form HUD-52671-A (6/91)
ref. Handbook 4350.3

This form must be completed so HUD can pay owners the difference between
the gross rent and the total tenant payment (housing assistance payments)
according to regulation. This information is necessary so the owner can
recoup money lost during vacancy, and money spent to fix damaged units and
cover rent when these expenses are unpaid by the vacating tenant.
Regulations require that owners complete this form using statutory formulas for calculating housing assistance payments, unpaid rent and tenant
damages and vacancy loss payments.
The statutes requiring the submission are S101, Housing and Urban
Development Act of 1965 (12 U.S.C. 1701s), S236(f)(2), National Housing Act
(12 U.S.C. 17152z-1), S8, United States Housing Act (42 U.S.C. 1437 f). The
regulations stipulating these rules are: 24 CFR 215, 236, 813, 880, 883, 884,
885, and 886. The administrative requirements for these forms are provided
in HUD Handbook 4350.3, Chapter 6. Copies of the statutes, regulations and
administrative requirements are provided in Appendix A.
HUD does not promise confidentiality but will not disclose data on a specific
project or tenant. No questions of a sensitive nature are asked in this form.

Submit an original and two copies

The Department of Housing & Urban Development is authorized to collect
this information by the U.S. Housing Act of 1937, as amended. The owner/
agent must provide all this information. The information provided will be used
by HUD for the following: (1) Review accuracy of funds requested by owner/
agent for tenants’ housing assistance payments and special claims payments.
(2) Review owner/agent computation of tenant assistance payment and
tenants’ rents using specific forms and formulas. (3) Evaluate the date owner/
agent re-certify assisted tenants. (4) Limit the number of Section 8 units that
may be leased to lower-income families whose incomes exceed 50% of the
area median income. (5) Restrict or prohibit the admission of tenants who are
ineligible for assistance. HUD may disclose this information to Federal, state,
and local agencies when relevant to civil, criminal, or regulatory investigations
and prosecutions. Otherwise, it will not be disclosed or released outside of
HUD, except as permitted or required by law. Providing all information is
mandatory, and failure to provide information will affect participation in HUD
programs.
Public reporting burden for this collection of information is estimated to
average 20 minutes 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 information unless that collection displays a valid OMB control
number.

form HUD-52671-A (6/91)
ref. Handbook 4350.3

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

Section 8 Special Claims for
Vacancies During Rent-up
Instructions. Follow guidelines
in HUD Handbook 4350.3,
Chapter 6
Unit Number

Unit Size
(No. of Bedrooms)

Project name

OMB Approval No. 2502-0182 (11/30/2003)

FHA project no.

Period Vacant
Effective Date of
Contract

To (date)

# days
vacant
(NTE 60)

Daily
Contract
Rent

(1)

(2)

Section 8 contract no.

Multiply
HUD's
columns 1 & limitation
2 & enter
here
(3)
(4)

Amount Claimed
(column 3 times
column 4)
(5)

0.80
0.80
0.80
0.80
0.80
0.80
0.80
0.80
0.80
0.80
0.80
0.80
0.80
0.80
0.80
0.80
0.80
0.80
0.80

I certify: (a) Units are in decent, safe, and sanitary condition, and are available for
occupancy during the vacancy period in which the payments are claimed. (b) I complied with
the HAP Agreement & implemented diligent marketing not fewer than 90 (60 days for
Substantial Rehabilitation) days prior to the anticipated date of initial occupancy. (c) I
complied with the requirement of the HUD-approved Affirmative Fair Housing Marketing
Plan (AFHMP) and all fair housing and equal opportunity requirements. (d) I took all feasible
action to fill the vacancy. (e) I did not reject eligible applicants. (f) I submitted a list of units
leased and unleased as of the effective date of the HAP contract. (g) All required documents
will be retained in the project's file for 3 years.

Also, enter this total in
Column 5 of HUD52670-A Part 2.

Total

HUD Field Office Review
Claim approved.
Claim adjusted. Reason:
Claim denied. Reason:
HUD official's name, signature, & date

Owner's printed name, signature, & date

HUD will prosecute false claims & statements. Conviction may result in criminal and/or civil penalties
(18 U.S.C. Sections 1001, 1010, 1012; 31 U.S.C. Sections 3729, 3802).
Submit an Original and two copies

form HUD-52671-B (6/91)
ref. Handbook 4350.3

This form must be completed so HUD can pay owners the difference
between the gross rent and the total tenant payment (housing assistance
payments) according to regulation. This information is necessary so the
owner can recoup money lost during vacancy, and money spent to fix
damaged units and cover rent when these expenses are unpaid by the
vacating tenant.
Regulations require that owners complete this form using statutory
formulas for calculating housing assistance payments, unpaid rent and
tenant damages and vacancy loss payments.
The statutes requiring the submission are S101, Housing and Urban
Development Act of 1965 (12 U.S.C. 1701s), S236(f)(2), National Housing
Act (12 U.S.C. 17152z-1), S8, United States Housing Act (42 U.S.C. 1437
f). The regulations stipulating these rules are: 24 CFR 215, 236, 813, 880,
883, 884, 885, and 886. The administrative requirements for these forms are
provided in HUD Handbook 4350.3, Chapter 6. Copies of the statutes,
regulations and administrative requirements are provided in Appendix A.
HUD does not promise confidentiality but will not disclose data on a
specific project or tenant. No questions of a sensitive nature are asked in this
form.

Submit an Original and two copies

The Department of Housing & Urban Development is authorized to collect
this information by the U.S. Housing Act of 1937, as amended. The owner/
agent must provide all this information. The information provided will be used
by HUD for the following: (1) Review accuracy of funds requested by owner/
agent for tenants’ housing assistance payments and special claims payments. (2) Review owner/agent computation of tenant assistance payment
and tenants’ rents using specific forms and formulas. (3) Evaluate the date
owner/agent re-certify assisted tenants. (4) Limit the number of Section 8
units that may be leased to lower-income families whose incomes exceed
50% of the area median income. (5) Restrict or prohibit the admission of
tenants who are ineligible for assistance. HUD may disclose this information
to Federal, state, and local agencies when relevant to civil, criminal, or
regulatory investigations and prosecutions. Otherwise, it will not be disclosed or released outside of HUD, except as permitted or required by law.
Providing all information is mandatory, and failure to provide information will
affect participation in HUD programs.
Public reporting burden for this collection of information is estimated to
average 0.33 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 information unless that collection displays a valid OMB
control number.

form HUD-52671-B (6/91)
ref. Handbook 4350.3

U.S. Department of Housing
and Urban Development
Office of Housing
Federal Housing Commissioner

Section 8 Special Claims
for Regular Vacancies
Project name
Instructions
Follow guidelines
in HUD Handbook
4350.3, Chapter 6
1.

Part A
(applies to the
following)
880: Section 8 New
Construction
881: Substantial
Rehabilitation
884: 515 Farmers
Home
885: Elderly Housing
886: LMSA Subpart A

Tenant's move-out
date

2.

No. days taken to
clean / repair unit

3.

Date unit ready for
occupancy

OMB Approval No. 2502-0182 (11/30/2003)

FHA project no.

Section 8 contract no.

Tenant name

Unit No.

4.

Date unit ready for 5. Date unit was
occup. + 60 days
re-rented

6. No. of days vacant
(Not to exceed 60.
Include day in line 3
but not day in line 5.)

7. Enter daily contract rent
(Divide contract rent in effect on move-out date by 30.)
8. Multiply lines 6 and 7 (Contract rent for days vacant)
9. Multiply line 8 by 0.80 (This is the most HUD will pay)
10. Enter amounts paid by other sources
(Security deposit, Title I, etc.)

(—)

11. Subtract line 10 from line 8
12. Compare line 9 with line 11 & enter the lesser amount
Enter in column 6 on HUD 52670-A Part 2.

Part B

13. Tenant's move-out
date

14. No. days taken to 15. Date unit ready for 16. Last day of mo. (or day before 17. Number of days vacant in first month
clean / repair unit
occupancy
move-in if in same month)
(Line 16 minus line 15, plus one day.
Not to exceed 30.)

(applies to)
886: Property
Disposition,
Subpart C

18. Enter daily assistance payment
(Divide assistance payment in effect on move-out date by 30.)
19. Multiply lines 17 by line 18
This is the most HUD will pay for the first month.
If vacancy continues for a second month, continue with line 20.
However, if a new tenant moved in the same month as the
previous tenant moved out, skip to line 25.
20. Day of second month the unit was rented
21. Subtract one (1) day from line 20
(Or enter 30 if the unit was not re-rented.)
22. Enter daily contract rent
(Divide contract rent in effect on move-out by 30.)
23. Multiply line 21 by line 22
24. Multiply line 23 by 0.80
This is the most HUD will pay for the second month.
25. Add lines 19 & 24
26. Enter amounts paid by other sources
(Security deposit, Title I, etc.)

(—)

27. Subtract line 26 from 25
Enter in column 6 on HUD 52670-A Part 2.

I certify: (a) Units are in decent, safe, and sanitary condition, and are available HUD Field Office Review
for occupancy during the vacancy period in which the payments are claimed. (b)
Claim approved.
The Owner / Agent did not cause the vacancy by violating the lease, the contract,
Claim adjusted. Reason:
or any applicable law. (c) I notified HUD or the contract administrator immediClaim denied. Reason:
ately upon learning of the vacancy, or prospective vacancy, and the reasons for
HUD official's name, signature, & date
it. (d) I complied with all HUD requirements on termination of tenancy (Chapter
4, Section 5 of Handbook 4350.3) if the vacancy was caused by an eviction. (e)
All documentation will be retained in the project's file for 3 years.
Owner's printed name, signature, & date

HUD will prosecute false claims & statements. Conviction may result in criminal and/or civil
penalties (18 U.S.C. Sections 1001, 1010, 1012; 31 U.S.C. Sections 3729, 3802).
Submit an Original and two copies

form HUD-52671-C (6/91)
ref. Handbook 4350.3

This form must be completed so HUD can pay owners the difference
between the gross rent and the total tenant payment (housing assistance
payments) according to regulation. This information is necessary so the
owner can recoup money lost during vacancy, and money spent to fix
damaged units and cover rent when these expenses are unpaid by the
vacating tenant.
Regulations require that owners complete this form using statutory
formulas for calculating housing assistance payments, unpaid rent and
tenant damages and vacancy loss payments.
The statutes requiring the submission are S101, Housing and Urban
Development Act of 1965 (12 U.S.C. 1701s), S236(f)(2), National Housing
Act (12 U.S.C. 17152z-1), S8, United States Housing Act (42 U.S.C. 1437
f). The regulations stipulating these rules are: 24 CFR 215, 236, 813, 880,
883, 884, 885, and 886. The administrative requirements for these forms are
provided in HUD Handbook 4350.3, Chapter 6. Copies of the statutes,
regulations and administrative requirements are provided in Appendix A.
HUD does not promise confidentiality but will not disclose data on a
specific project or tenant. No questions of a sensitive nature are asked in this
form.

Submit an Original and two copies

The Department of Housing & Urban Development is authorized to collect
this information by the U.S. Housing Act of 1937, as amended. The owner/
agent must provide all this information. The information provided will be used
by HUD for the following: (1) Review accuracy of funds requested by owner/
agent for tenants’ housing assistance payments and special claims payments. (2) Review owner/agent computation of tenant assistance payment
and tenants’ rents using specific forms and formulas. (3) Evaluate the date
owner/agent re-certify assisted tenants. (4) Limit the number of Section 8
units that may be leased to lower-income families whose incomes exceed
50% of the area median income. (5) Restrict or prohibit the admission of
tenants who are ineligible for assistance. HUD may disclose this information
to Federal, state, and local agencies when relevant to civil, criminal, or
regulatory investigations and prosecutions. Otherwise, it will not be disclosed or released outside of HUD, except as permitted or required by law.
Providing all information is mandatory, and failure to provide information will
affect participation in HUD programs.
Public reporting burden for this collection of information is estimated to
average 0.33 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 information unless that collection displays a valid OMB
control number.

form HUD-52671-C (6/91)
ref. Handbook 4350.3

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

Section 8 Special Claims
for Debt Service
Instructions: Follow guidelines in
HUD Handbook 4350.3, Chapter 6
Unit number

Unit size
(No. of Bedrooms)

Project name

OMB Approval No. 2502-0182 (11/30/2003)

FHA project no.

Period vacant
From (date)

No. of days vacant

To (date)

Section 8 contract no.

Daily debt ser. attributed
Amount Claimed
to that unit from HAP con- (column 1 x column 2)
tract (exhibit 2)

(2)

(1)

(3)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18

I certify: (a) Units are in decent, safe, and sanitary condition, and are available for occupancy during
A
the vacancy period in which the payments are claimed. (b) I took all appropriate actions to market
and fill the vacant units. (c) The project shows a net operating loss on an unaudited form HUD-92410, B
Profit & Loss Statement.
Owner's printed name, signature, & date

C

Total
Enter operating loss
from HUD-92410
Enter lesser of A
or B. Also enter in
column 7 of HUD
52670-A Part 2.

HUD will prosecute false claims & statements. Conviction may result in criminal and/or civil penalties. (18 U.S.C. 1001, 1010, 1012; 31 U.S.C. 3729, 3802)

HUD Field Office Review
Claim approved.
Claim adjusted.
Claim denied. Reason:
HUD official's name, signature, & date X
Submit an Original and two copies

form HUD-52671-D (6/91)
ref Handbook 4350.3

This form must be completed so HUD can pay owners the difference
between the gross rent and the total tenant payment (housing assistance
payments) according to regulation. This information is necessary so the
owner can recoup money lost during vacancy, and money spent to fix
damaged units and cover rent when these expenses are unpaid by the
vacating tenant.
Regulations require that owners complete this form using statutory
formulas for calculating housing assistance payments, unpaid rent and
tenant damages and vacancy loss payments.
The statutes requiring the submission are S101, Housing and Urban
Development Act of 1965 (12 U.S.C. 1701s), S236(f)(2), National Housing
Act (12 U.S.C. 17152z-1), S8, United States Housing Act (42 U.S.C. 1437
f). The regulations stipulating these rules are: 24 CFR 215, 236, 813, 880,
883, 884, 885, and 886. The administrative requirements for these forms are
provided in HUD Handbook 4350.3, Chapter 6. Copies of the statutes,
regulations and administrative requirements are provided in Appendix A.
HUD does not promise confidentiality but will not disclose data on a
specific project or tenant. No questions of a sensitive nature are asked in this
form.

Submit an Original and two copies

The Department of Housing & Urban Development is authorized to collect
this information by the U.S. Housing Act of 1937, as amended. The owner/
agent must provide all this information. The information provided will be used
by HUD for the following: (1) Review accuracy of funds requested by owner/
agent for tenants’ housing assistance payments and special claims payments. (2) Review owner/agent computation of tenant assistance payment
and tenants’ rents using specific forms and formulas. (3) Evaluate the date
owner/agent re-certify assisted tenants. (4) Limit the number of Section 8
units that may be leased to lower-income families whose incomes exceed
50% of the area median income. (5) Restrict or prohibit the admission of
tenants who are ineligible for assistance. HUD may disclose this information
to Federal, state, and local agencies when relevant to civil, criminal, or
regulatory investigations and prosecutions. Otherwise, it will not be disclosed or released outside of HUD, except as permitted or required by law.
Providing all information is mandatory, and failure to provide information will
affect participation in HUD programs.
Public reporting burden for this collection of information is estimated to
average 0.33 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 information unless that collection displays a valid OMB
control number.

form HUD-52671-D (6/91)
ref Handbook 4350.3

Appendix 13
Form HUD-93104, Monthly Report of
Excess Income

Monthly Report of Excess Income
Section 236 Projects

U.S. Department of Housing
and Urban Development
Office of Housing
Federal Housing Commissioner

OMB Approval No. 2502-0086
(exp. 09/30/2003)

Important: Follow the instructions on the back to prepare this form.

Submit this form by the 10th of the month following the month covered by this report.
FHA Project Number

Project Name & Address

Reporting Period (mm/yyyy)

Complete this block only if there is a
payment due HUD

Mail this report to (This form is designed to fit a window envelope.)

Check Number:

Amount:

Excess Rental Income
P.O. Box 360333M
Pittsburgh, PA 15250

fold line

Project Owner's Name & Address

Phone Number

Management Agent's Name & Address

Employer ID Number

Phone Number

Employer ID Number

1. Total gross rental collections in excess of approved basic rental per unit for all units in the project

$

2. Less amount retained for HUD-approved purposes

$(

3. Total Net Excess Income due HUD this month

$

)

Certification: I certify that the information on this form is true 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)
Type the Name & Phone No. of the person preparing this report (include area code)

Name of Reviewing Mortgagor Official & Phone Number

Title

Title

Signature

Previous editions are obsolete.

Date (mm/dd/yyyy)

Signature

Date (mm/dd/yyyy)

form HUD-93104 (2/98)

Public reporting burden for this collection of information is estimated to average 30 minutes 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 collect this information, and you are not required to complete this form, unless it displays a currently valid OMB control number.
This information is collected to obtain full benefits authorized by the amended section 236(g) of the National Housing Act. The information will enable
HUD to ensure that project owners carry out their statutory obligations to remit to HUD all Excess Income that HUD has not authorized them to retain.
Responses are required to obtain and retain the benefits authorized and mandated by section 236 of the Act. The information is considered nonsensitive,
and there are no assurances of confidentiality.
Privacy Act Statement: The Department of Housing and Urban Development (HUD) is authorized to collect this information by Section 236 of the National
Housing Act, as amended, and the Employer Identification Number (EIN) by the Housing & Community Development Act of 1987, 42 U.S.C 3543 . The
information concerning the monthly reporting of excess income is being collected by HUD to: (1) ensure project owners comply with the program
requirements to accumulate, safeguard and pay HUD all rental charges collected in excess of the basic rental charges, (2) recover and enforce collection
actions through repayment plans and/or offset of future subsidy billings in accordance with 24 CFR 17, administrative claims, and assess civil money
penalties pursuant to Section 416 of the 1987 Housing and Community Development Act, as well as, (3) automate financial reporting needs. The EIN
is used as a unique identifier for closer monitoring of owners and agents. HUD may disclose this information to Federal, State and local agencies when
relevant to civil, criminal, or regulatory investigations and prosecutions. It will not be otherwise disclosed or released outside of HUD, except as required
and permitted by law. Failure to provide the information could affect your future participation in HUD programs.

Instructions for Preparing form HUD-93104,
Monthly Report of Excess Income
This form is designed to fit a window envelope.
The following (and similar) items are excluded from the computations: Late
fees, NSF Check fees, utility surcharges, security deposit damage surcharges, Section 8 damage surcharges, Section 8 vacancy payments, local
tax surcharges, and separate parking or cable television charges if these
amenities are not included in the Basic Rent.
All Section 236 project owners (Insured, Non-insured, and HUD-held) must
remit each month all rental receipts in excess of each unit's approved Basic
Rental Rate.
All Section 236 mortgagors are to:
1. Prepare and mail form HUD-93104 by the tenth of each month to report
the prior month's collections. A report must be submitted each month,
whether or not a remittance is required.
2. Forward the original form HUD-93104 to the address shown on the form,
with a copy to the local HUD Office that has jurisdiction over the project.
3. Keep copies of the completed forms as part of the books and records of
the project for at least seven years from the dates the forms are prepared.

A prorated amount of Excess Income must be computed and remitted
when only a partial month's rent payment is due and paid. Amounts
received in the current month for rents due in other months are to be
applied to sums due the Operating Account and due HUD for those other
months. If the information is not already available or readily extractable
from the project's rent rolls or ledger folios, the mortgagor must prepare
a detailed monthly schedule of each unit that did not receive Rent
Supplement, RAP, or Section 8 Assistance of any type; this schedule (or
the rent roll) must show the basic rental charge for each unit and the
amount collected as rent in excess of the basic rental charge for each unit.
This schedule (or rent roll) must be prepared each month regardless of
whether Excess Income is being remitted for that month. This schedule
(or rent roll) must show the following information for each unit that does
not receive Rent Supplement, RAP, or Section 8 Assistance of any type,
and it must be presented to the independent public accountant performing
the annual audit of the mortgagor at the time of the audit:
Unit
Number

Tenant
Name

Basic
Rent

Tenant
Rental
Payment

Excess
Above
Basic Rent

4. Attach a check for full payment of the total amount shown due, indicating
the project number and the month and year of the Excess Income
payment on the check.

Previous editions are obsolete.

form HUD-93104 (2/98)

Appendix 14
Fact Sheets – How Rent is Determined
• Memorandum February 5, 2002: Fact Sheets for
Project-Based Assistance Programs
• Below Market Interest Rate (BMIR) Fact Sheet
• Project-Based Section 8 Fact Sheet
• Rental Assistance Payments (RAP) Fact Sheet
• Rent Supplement Fact Sheet
• Section 202/162 – Project Assistance
Contract (PAC)
Section 202/811 – Project Rental Assistance
Contract (PRAC) Fact Sheet
• Section 236 Fact Sheet

U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT
WASHINGTON, D.C. 20410-8000

OFFICE OF THE ASSISTANT SECRETARY
FOR HOUSING-FEDERAL HOUSING COMMISSIONER

February 5, 2002
MEMORANDUM FOR: All Hub Directors
All Program Center Directors
All Performance-Based Contract Administrators
All Contract Administrators
All Owners and Agents of HUD-Assisted Properties

FROM: John C. Weicher, Assistant Secretary for Housing - Federal Housing
Commissioner, H

SUBJECT: Fact Sheets for Project-Based Assistance Programs

As part of the Department’s continuing effort to reduce errors in the administration of its
rental housing assistance programs, the Office of Housing is in the process of developing tools to
assist owners, agents, and tenants in determining the correct rent and to ensure that the “right
benefit goes to the right person.” The attached Fact Sheets describe how rents are determined
under the various project-based assistance programs.
The Fact Sheets are to be provided to owners, agents, for distribution to prospective and
current residents of HUD-assisted housing. The Fact Sheets inform residents of the types of
income they need to report to the owner and the exclusions from income the owner must allow
when determining the household’s annual income. They also informs residents of the deductions
they may be entitled to receive to arrive at the adjusted income used in determining their rent.
The Fact Sheets also serve as a reminder to owners and agents of their responsibilities for
ensuring that accurate information is used in determining rent and that the rent is calculated
correctly. The Fact Sheets are posted on the web at www.hud.gov/offices/hsg/hsgmulti.cfm
under Rental Housing Income Integrity Improvement Project (RHIIP).
Owners are responsible for making sure that the procedures used for determining rent and
rental assistance at their property are adequate and that they reflect current provisions and
requirements. Owners are also expected to maintain a high standard of accuracy in the rent
determination process and must ensure the following:
•

Project staff is properly trained in the rent determination process.

•

The right questions are asked of prospective and current residents in order to obtain
all of the sources of income of the household members and for determining the
appropriate exclusions and deductions.

•

Third party verifications are obtained and documented for all income, assets and
expenses related to deductions from annual income and any other factors that affect
the determination of adjusted income.

•

The resident’s portion of the rent and the rental assistance provided by HUD are
calculated correctly.

•

Certifications are completed on time (initial, annual, and interim).

•

Residents are notified of rent changes and provided copies of the rent determinations.

•

Tenant data is accurate and is transmitted to the Tenant Rental Assistance
Certification System (TRACS) on a timely basis.

The attached Fact Sheets are a summary of current HUD Polices and regulations
concerning resident income certification(s). We trust that owners and agents will distribute them
to residents as part of an educational process that explains resident entitlements and
responsibilities.
Attachments

FACT SHEET
For HUD ASSISTED RESIDENTS

Below Market Interest Rate
(BMIR)

OAs’ Responsibilities:
•
•
•
•
•

“HOW YOUR RENT IS
DETERMINED”

•

Office of Housing

•
•

January 2002

This Fact Sheet is a general guide to inform the
Owner/Management Agents (OA) and HUDassisted residents of the responsibilities and rights
regarding income disclosure and verification.

•
•

Residents’ Responsibilities:
•
•
•
•
•
•

Why Determining Income and Rent
Correctly is Important

Obtain accurate income information
Verify resident income
Ensure residents receive the exclusions to which
they are entitled
Accurately calculate Tenant Rent
Provide tenants a copy of lease agreement and
income and rent determinations
Recalculate rent when changes in family
composition are reported
Recalculate rent when resident income decreases
Recalculate rent when resident income increases by
$200 or more per month
Provide information on OA policies upon request
Notify residents of any changes in requirements or
practices for reporting income or determining rent

Provide accurate family composition information
Report all income
Keep copies of papers, forms, and receipts which
document income and expenses
Report changes in family composition and income
occurring between annual recertifications
Sign consent forms for income verification
Follow lease requirements and house rules

Income Determinations

Department of Housing and Urban Development studies
show that many resident families pay incorrect rent. The
main causes of this problem are:

A family’s anticipated gross income determines not only
eligibility, but also determines the rent a family will pay.
The anticipated income, subject to exclusions the family
will receive during the next twelve (12) months, is used
to determine the family’s rent.

•
•

What is Annual Income?

Under-reporting of income by resident families, and
OAs not granting exclusions and deductions to
which resident families are entitled.

OAs and residents all have a responsibility in ensuring
that the correct rent is paid.

Gross Income – Income Exclusions = Annual Income

Determining Tenant Rent
Below Market Interest Rate (BMIR) Rent
Formula:
• At move-in or initial occupancy, the family pays the
contract rent
• At recertification, they continue to pay the same rent
unless their income is equal to or higher than
110% of the BMIR income limit. If the income
has risen to 110% of the BMIR income limit, they
pay the higher of the BMIR Market Rent or the
amount they now pay.

Income and Assets
HUD assisted residents are required to report all income
from all sources to the Owner or Agent (OA).
Exclusions to income are part of the tenant rent process.
When determining the amount of income from assets to
be included in annual income, the actual income derived
from the assets is included except when the cash value of
all of the assets is in excess of $5,000, then the amount
included in annual income is the higher of 2% of the
total assets or the actual income derived from the assets.
Annual Income Includes:
• Full amount (before payroll deductions) of wages
and salaries, overtime pay, commissions, fees, tips
and bonuses and other compensation for personal
services
• Net income from the operation of a business or
profession
• Interest, dividends and other net income of any kind
from real or personal property (See Assets
Include/Assets Do Not Include below)
• Full amount of periodic amounts received from
Social Security, annuities, insurance policies,
retirement funds, pensions, disability or death
benefits and other similar types of periodic receipts,
including lump-sum amount or prospective monthly
amounts for the delayed start of a periodic amount
• Payments in lieu of earnings, such as unemployment
and disability compensation, worker’s compensation
and severance pay
• Welfare assistance
• Periodic and determinable allowances, such as
alimony and child support payments and regular

•

contributions or gifts received from organizations or
from persons not residing in the dwelling
All regular pay, special pay and allowances of a
member of the Armed Forces (except for special pay
for exposure to hostile fire)

Assets Include:
• Stocks, bonds, Treasury bills, certificates of deposit,
money market accounts
• Individual retirement and Keogh accounts
• Retirement and pension funds
• Cash held in savings and checking accounts, safe
deposit boxes, homes, etc.
• Cash value of whole life insurance policies available
to the individual before death
• Equity in rental property and other capital
investments
• Personal property held as an investment
• Lump sum receipts or one-time receipts
• Mortgage or deed of trust held by an applicant
• Assets disposed of for less than fair market value.
Assets Do Not Include:
• Necessary personal property (clothing, furniture,
cars, wedding ring, vehicles specially equipped for
persons with disabilities)
• Interests in Indian trust land
• Term life insurance policies
• Equity in the cooperative unit in which the family
lives
• Assets that are part of an active business
• Assets that are not effectively owned by the
applicant
or are held in an individual’s name but:
• The assets and any income they earn accrue to
the benefit of someone else who is not a member
of the household, and
• that the other person is responsible for income
taxes incurred on income generated by the assets
• Assets that are not accessible to the applicant and
provide no income to the applicant (Example: A
battered spouse owns a house with her husband.
Due to the domestic situation, she receives no
income from the asset and cannot convert the asset
to cash.)
• Assets disposed of for less than fair market value as
a result of:
• Foreclosure
• Bankruptcy

2

•

Divorce or separation agreement if the applicant
or resident receives important consideration not
necessarily in dollars.

Exclusions from Annual Income:
• Income from the employment of children (including
foster children) under the age of 18
• Payment received for the care of foster children or
foster adults (usually persons with disabilities,
unrelated to the tenant family, who are unable to live
alone
• Lump-sum additions to family assets, such as
inheritances, insurance payments (including
payments under health and accident insurance and
worker’s compensation), capital gains and settlement
for personal or property losses
• Amounts received by the family that are specifically
for, or in reimbursement of, the cost of medical
expenses for any family member
• Income of a live-in aide
• The full amount of student financial assistance either
paid directly to the student or to the educational
institution
• The special pay to a family member serving in the
Armed Forces who is exposed to hostile fire
• Amounts received under training programs funded
by HUD
• Amounts received by a person with a disability that
are disregarded for a limited time for purposes of
Supplemental Security Income eligibility and
benefits because they are set aside for use under a
Plan to Attain Self-Sufficiency (PASS)
• Amounts received by a participant in other publicly
assisted programs which are specifically for or in
reimbursement of out-of-pocket expenses incurred
(special equipment, clothing, transportation, child
care, etc.) and which are made solely to allow
participation in a specific program
• Resident service stipend (not to exceed $200 per
month)
• Incremental earnings and benefits resulting to any
family member from participation in qualifying State
or local employment training programs and training
of a family member as resident management staff
• Temporary, non-recurring or sporadic income
(including gifts)
•

Reparation payments paid by a foreign government
pursuant to claims filed under the laws of that

•
•
•

•
•

government by persons who were persecuted during
the Nazi era
Earnings in excess of $480 for each full time student
18 years old or older (excluding head of household,
co-head or spouse)
Adoption assistance payments in excess of $480 per
adopted child
Deferred periodic payments of supplemental security
income and social security benefits that are received
in a lump sum amount or in prospective monthly
amounts
Amounts received by the family in the form of
refunds or rebates under State of local law for
property taxes paid on the dwelling unit
Amounts paid by a State agency to a family with a
member who has a developmental disability and is
living at home to offset the cost of services and
equipment needed to keep the developmentally
disabled family member at home

Federally Mandated Exclusions:
• Value of the allotment provided to an eligible
household under the Food Stamp Act of 1977
• Payments to Volunteers under the Domestic
Volunteer Services Act of 1973
• Payments received under the Alaska Native Claims
Settlement Act
• Income derived from certain submarginal land of the
US that is held in trust for certain Indian Tribes
• Payments or allowances made under the Department
of Health and Human Services’ Low-Income Home
Energy Assistance Program
• Payments received under programs funded in whole
or in part under the Job Training Partnership Act
• Income derived from the disposition of funds to the
Grand River Band of Ottawa Indians
• The first $2000 of per capita shares received from
judgment funds awarded by the Indian Claims
Commission or the US. Claims Court, the interests
of individual Indians in trust or restricted lands,
including the first $2000 per year of income
received by individual Indians from funds derived
from interests held in such trust or restricted lands
•

Amounts of scholarships funded under Title IV of
the Higher Education Act of 1965, including awards
under the Federal work-study program or under the
Bureau of Indian Affairs student assistance programs

3

•
•

•
•

•
•

•
•
•

•

Payments received from programs funded under
Title V of the Older Americans Act of 1985
Payments received on or after January 1, 1989, from
the Agent Orange Settlement Fund or any other fund
established pursuant to the settlement in In Re
Agent-product liability litigation
Payments received under the Maine Indian Claims
Settlement Act of 1980
The value of any child care provided or arranged (or
any amount received as payment for such care or
reimbursement for costs incurred for such care)
under the Child Care and Development Block Grant
Act of 1990
Earned income tax credit (EITC) refund payments
on or after January 1, 1991
Payments by the Indian Claims Commission to the
Confederated Tribes and Bands of Yakima Indian
Nation or the Apache Tribe of Mescalero
Reservation
Allowance, earnings and payments to AmeriCorps
participants under the National and Community
Service Act of 1990
Any allowance paid under the provisions of
38U.S.C. 1805 to a child suffering from spina bifida
who is the child of a Vietnam veteran
Any amount of crime victim compensation (under
the Victims of Crime Act) received through crime
victim assistance (or payment or reimbursement of
the cost of such assistance) as determined under the
Victims of Crime Act because of the commission of
a crime against the applicant under the Victims of
Crime Act
Allowances, earnings and payments to individuals
participating under the Workforce Investment Act of
1998.

Reference Materials
Regulations:
• General HUD Program Requirements;24CFR Part 5
Handbook:
• 4350.3, Occupancy Requirements of Subsidized
Multifamily Housing Programs
Notices:
• “Federally Mandated Exclusions” Notice 66 FR
4669, April 20, 2001
For More Information:
Find out more about HUD’s programs on HUD’s
Internet homepage at http://www.hud.gov

4

OAs’ Responsibilities:

FACT SHEET
For HUD ASSISTED RESIDENTS

Project-Based Section 8
“HOW YOUR RENT IS
DETERMINED”
Office of Housing

•
•
•
•
•
•
•
•
•

•

January 2002

Obtain accurate income information
Verify resident income
Ensure residents receive the exclusions and
deductions to which they are entitled
Accurately calculate Tenant Rent
Provide tenants a copy of lease agreement and
income and rent determinations Recalculate rent
when changes in family composition are reported
Recalculate rent when resident income decreases
Recalculate rent when resident income increases by
$200 or more per month
Recalculate rent every 90 days when resident claims
minimum rent hardship exemption
Provide information on OA policies upon request
Notify residents of any changes in requirements or
practices for reporting income or determining rent

Residents’ Responsibilities:
This Fact Sheet is a general guide to inform the
Owner/Management Agents (OA) and HUDassisted residents of the responsibilities and rights
regarding income disclosure and verification.

•
•
•
•
•
•

Why Determining Income and Rent
Correctly is Important
Department of Housing and Urban Development studies
show that many resident families pay incorrect rent. The
main causes of this problem are:
•
•

Under-reporting of income by resident families, and
OAs not granting exclusions and deductions to
which resident families are entitled.

Provide accurate family composition information
Report all income
Keep copies of papers, forms, and receipts which
document income and expenses
Report changes in family composition and income
occurring between annual recertifications
Sign consent forms for income verification
Follow lease requirements and house rules

Income Determinations
A family’s anticipated gross income determines not only
eligibility for assistance, but also determines the rent a
family will pay and the subsidy required. The
anticipated income, subject to exclusions and deductions
the family will receive during the next twelve (12)
months, is used to determine the family’s rent.
What is Annual Income?
Gross Income – Income Exclusions = Annual Income

OAs and residents all have a responsibility in ensuring
that the correct rent is paid.

What is Adjusted Income?
Annual Income – Deductions = Adjusted Income

Determining Tenant Rent
Project-Based Section 8 Rent Formula:
The rent a family will pay is the highest of the following
amounts:
• 30% of the family’s monthly adjusted income
• 10% of the family’s monthly income
• Welfare rent or welfare payment from agency
to assist family in paying housing costs.
OR
• $25.00 Minimum Rent

Income and Assets
HUD assisted residents are required to report all income
from all sources to the Owner or Agent (OA).
Exclusions to income and deductions are part of the
tenant rent process.
When determining the amount of income from assets to
be included in annual income, the actual income derived
from the assets is included except when the cash value of
all of the assets is in excess of $5,000, then the amount
included in annual income is the higher of 2% of the
total assets or the actual income derived from the assets.
Annual Income Includes:
• Full amount (before payroll deductions) of wages
and salaries, overtime pay, commissions, fees, tips
and bonuses and other compensation for personal
services
• Net income from the operation of a business or
profession
• Interest, dividends and other net income of any kind
from real or personal property (See Assets
Include/Assets Do Not Include below)
• Full amount of periodic amounts received from
Social Security, annuities, insurance policies,
retirement funds, pensions, disability or death
benefits and other similar types of periodic receipts,
including lump-sum amount or prospective monthly
amounts for the delayed start of a periodic amount
• Payments in lieu of earnings, such as unemployment
and disability compensation, worker’s compensation
and severance pay
• Welfare assistance
• Periodic and determinable allowances, such as
alimony and child support payments and regular

•

contributions or gifts received from organizations or
from persons not residing in the dwelling
All regular pay, special pay and allowances of a
member of the Armed Forces (except for special pay
for exposure to hostile fire)

Assets Include:
• Stocks, bonds, Treasury bills, certificates of deposit,
money market accounts
• Individual retirement and Keogh accounts
• Retirement and pension funds
• Cash held in savings and checking accounts, safe
deposit boxes, homes, etc.
• Cash value of whole life insurance policies available
to the individual before death
• Equity in rental property and other capital
investments
• Personal property held as an investment
• Lump sum receipts or one-time receipts
• Mortgage or deed of trust held by an applicant
• Assets disposed of for less than fair market value.
Assets Do Not Include:
• Necessary personal property (clothing, furniture,
cars, wedding ring, vehicles specially equipped for
persons with disabilities)
• Interests in Indian trust land
• Term life insurance policies
• Equity in the cooperative unit in which the family
lives
• Assets that are part of an active business
• Assets that are not effectively owned by the
applicant
or are held in an individual’s name but:
• The assets and any income they earn accrue to
the benefit of someone else who is not a member
of the household, and
• that other person is responsible for income taxes
incurred on income generated by the assets
• Assets that are not accessible to the applicant and
provide no income to the applicant (Example: A
battered spouse owns a house with her husband.
Due to the domestic situation, she receives no
income from the asset and cannot convert the asset
to cash.)
• Assets disposed of for less than fair market value as
a result of:
• Foreclosure
• Bankruptcy

2

•

Divorce or separation agreement if the applicant
or resident receives important consideration not
necessarily in dollars.

Exclusions from Annual Income:
• Income from the employment of children (including
foster children) under the age of 18
• Payment received for the care of foster children or
foster adults (usually persons with disabilities,
unrelated to the tenant family, who are unable to live
alone
• Lump-sum additions to family assets, such as
inheritances, insurance payments (including
payments under health and accident insurance and
worker’s compensation), capital gains and settlement
for personal or property losses
• Amounts received by the family that are specifically
for, or in reimbursement of, the cost of medical
expenses for any family member
• Income of a live-in aide
• The full amount of student financial assistance either
paid directly to the student or to the educational
institution
• The special pay to a family member serving in the
Armed Forces who is exposed to hostile fire
• Amounts received under training programs funded
by HUD
• Amounts received by a person with a disability that
are disregarded for a limited time for purposes of
Supplemental Security Income eligibility and
benefits because they are set aside for use under a
Plan to Attain Self-Sufficiency (PASS)
• Amounts received by a participant in other publicly
assisted programs which are specifically for or in
reimbursement of out-of-pocket expenses incurred
(special equipment, clothing, transportation, child
care, etc.) and which are made solely to allow
participation in a specific program
• Resident service stipend (not to exceed $200 per
month)
• Incremental earnings and benefits resulting to any
family member from participation in qualifying State
or local employment training programs and training
of a family member as resident management staff
• Temporary, non-recurring or sporadic income
(including gifts)
• Reparation payments paid by a foreign government
pursuant to claims filed under the laws of that
government by persons who were persecuted during
the Nazi era

•
•
•

•
•

Earnings in excess of $480 for each full time student
18 years old or older (excluding head of household,
co-head or spouse)
Adoption assistance payments in excess of $480 per
adopted child
Deferred periodic payments of supplemental security
income and social security benefits that are received
in a lump sum amount or in prospective monthly
amounts
Amounts received by the family in the form of
refunds or rebates under State of local law for
property taxes paid on the dwelling unit
Amounts paid by a State agency to a family with a
member who has a developmental disability and is
living at home to offset the cost of services and
equipment needed to keep the developmentally
disabled family member at home

Federally Mandated Exclusions:
• Value of the allotment provided to an eligible
household under the Food Stamp Act of 1977
• Payments to Volunteers under the Domestic
Volunteer Services Act of 1973
• Payments received under the Alaska Native Claims
Settlement Act
• Income derived from certain submarginal land of the
US that is held in trust for certain Indian Tribes
• Payments or allowances made under the Department
of Health and Human Services’ Low-Income Home
Energy Assistance Program
• Payments received under programs funded in whole
or in part under the Job Training Partnership Act
• Income derived from the disposition of funds to the
Grand River Band of Ottawa Indians
• The first $2000 of per capita shares received from
judgment funds awarded by the Indian Claims
Commission or the US. Claims Court, the interests
of individual Indians in trust or restricted lands,
including the first $2000 per year of income
received by individual Indians from funds derived
from interests held in such trust or restricted lands
•

•

Amounts of scholarships funded under Title IV of
the Higher Education Act of 1965, including awards
under the Federal work-study program or under the
Bureau of Indian Affairs student assistance programs
Payments received from programs funded under
Title V of the Older Americans Act of 1985

3

•

•
•

•
•

•
•
•

•

Payments received on or after January 1, 1989, from
the Agent Orange Settlement Fund or any other fund
established pursuant to the settlement in In Re
Agent-product liability litigation
Payments received under the Maine Indian Claims
Settlement Act of 1980
The value of any child care provided or arranged (or
any amount received as payment for such care or
reimbursement for costs incurred for such care)
under the Child Care and Development Block Grant
Act of 1990
Earned income tax credit (EITC) refund payments
on or after January 1, 1991
Payments by the Indian Claims Commission to the
Confederated Tribes and Bands of Yakima Indian
Nation or the Apache Tribe of Mescalero
Reservation
Allowance, earnings and payments to AmeriCorps
participants under the National and Community
Service Act of 1990
Any allowance paid under the provisions of
38U.S.C. 1805 to a child suffering from spina bifida
who is the child of a Vietnam veteran
Any amount of crime victim compensation (under
the Victims of Crime Act) received through crime
victim assistance (or payment or reimbursement of
the cost of such assistance) as determined under the
Victims of Crime Act because of the commission of
a crime against the applicant under the Victims of
Crime Act
Allowances, earnings and payments to individuals
participating under the Workforce Investment Act of
1998.

Deductions:
•
•
•
•

•

$480 for each dependent including full time students
or persons with a disability
$400 for any elderly family or disabled family
Unreimbursed medical expenses of any elderly
family or disabled family that total more than 3% of
Annual Income
Unreimbursed reasonable attendant care and
auxiliary apparatus expenses for disabled family
member(s) to allow family member(s) to work that
total more than 3% of Annual Income
If an elderly family has both unreimbursed medical
expenses and disability assistance expenses, the

•

family’s 3% of income expenditure is applied only
one time.
Any reasonable child care expenses for children
under age 13 necessary to enable a member of the
family to be employed or to further his or her
education.

Reference Materials
Legislation:
• Quality Housing and Work Responsibility Act of
1998, Public Law 105-276, 112 Stat. 2518 which
amended the United States Housing Act of 1937, 42
USC 2437, et seq.
Regulations:
• General HUD Program Requirements;24 CFR Part 5
• Changes to Admission and Occupancy
Requirements in the Public Housing and Section 8
Housing Assistance Programs; Final Rule, 65 FR
16692, March 29, 2000; 24 CFR 880 et al.
• Determining Adjusted Income in HUD Programs
Serving Persons with Disabilities; Requiring
Mandatory Deductions for Certain Expenses; and
Disallowance for Earned Income, 65 FR 4608,
August 21, 2000; 24 CFR Parts 5, 92, et al.
Handbook:
• 4350.3, Occupancy Requirements of Subsidized
Multifamily Housing Programs
Notices:
• “Federally Mandated Exclusions” Notice 66 FR
4669, April 20, 2001
• Notice H 00-18, Admission and Occupancy of the
Quality Housing and Work Responsibility Act of
1998 (QHWRA) for Multifamily Housing Programs
For More Information:
Find out more about HUD’s programs on HUD’s
Internet homepage at http://www.hud.gov

4

FACT SHEET

OAs’ Responsibilities:

For HUD ASSISTED RESIDENTS

•
•
•

Rental Assistance Payments (RAP)

•
•

“HOW YOUR RENT IS
DETERMINED”

•

Office of Housing

•
•

•
•

January 2002

Obtain accurate income information
Verify resident income
Ensure residents receive the exclusions and
deductions to which they are entitled
Accurately calculate Tenant Rent
Provide tenants a copy of lease agreement and
income and rent determinations
Recalculate rent when changes in family
composition are reported
Recalculate rent when resident income decreases
Recalculate rent when resident income increases by
$200 or more per month
Provide information on OA policies upon request
Notify residents of any changes in requirements or
practices for reporting income or determining rent

Residents’ Responsibilities:
This Fact Sheet is a general guide to inform the
Owner/Management Agents (OA) and HUDassisted residents of the responsibilities and rights
regarding income disclosure and verification.

•
•
•
•
•
•

Why Determining Income and Rent
Correctly is Important
Department of Housing and Urban Development studies
show that many resident families pay incorrect rent. The
main causes of this problem are:
•
•

Under-reporting of income by resident families, and
OAs not granting exclusions and deductions to
which resident families are entitled.

Provide accurate family composition information
Report all income
Keep copies of papers, forms, and receipts which
document income and expenses
Report changes in family composition and income
occurring between annual recertifications
Sign consent forms for income verification
Follow lease requirements and house rules

Income Determinations
A family’s anticipated gross income determines not only
eligibility for assistance, but also determines the rent a
family will pay and the subsidy required. The
anticipated income, subject to exclusions and deductions
the family will receive during the next twelve (12)
months, is used to determine the family’s rent.
What is Annual Income?
Gross Income – Income Exclusions = Annual Income

OAs and residents all have a responsibility in ensuring
that the correct rent is paid.

What is Adjusted Income?
Annual Income – Deductions = Adjusted Income

Determining Tenant Rent

Rental Assistance Payment (RAP) Rent
Formula:
The rent a family will pay is the highest of the following
amounts:
• 30% of the family’s monthly adjusted income
• 10% of the family’s monthly income
• Welfare rent or welfare payment from agency
to assist family in paying housing costs.
•

Note: An owner may admit an applicant to the RAP
program only if the Total Tenant Payment is less than
the gross rent for the unit.

Income and Assets
HUD assisted residents are required to report all income
from all sources to the Owner or Agent (OA).
Exclusions to income and deductions are part of the
tenant rent process.
When determining the amount of income from assets to
be included in annual income, the actual income derived
from the assets is included except when the cash value of
all of the assets is in excess of $5,000, then the amount
included in annual income is the higher of 2% of the
total assets or the actual income derived from the assets.
Annual Income Includes:
• Full amount (before payroll deductions) of wages
and salaries, overtime pay, commissions, fees, tips
and bonuses and other compensation for personal
services
• Net income from the operation of a business or
profession
• Interest, dividends and other net income of any kind
from real or personal property (See Assets
Include/Assets Do Not Include below)
• Full amount of periodic amounts received from
Social Security, annuities, insurance policies,
retirement funds, pensions, disability or death
benefits and other similar types of periodic receipts,
including lump-sum amount or prospective monthly
amounts for the delayed start of a periodic amount
• Payments in lieu of earnings, such as unemployment
and disability compensation, worker’s compensation
and severance pay
• Welfare assistance
• Periodic and determinable allowances, such as
alimony and child support payments and regular

•

contributions or gifts received from organizations or
from persons not residing in the dwelling
All regular pay, special pay and allowances of a
member of the Armed Forces (except for special pay
for exposure to hostile fire)

Assets Include:
• Stocks, bonds, Treasury bills, certificates of deposit,
money market accounts
• Individual retirement and Keogh accounts
• Retirement and pension funds
• Cash held in savings and checking accounts, safe
deposit boxes, homes, etc.
• Cash value of whole life insurance policies available
to the individual before death
• Equity in rental property and other capital
investments
• Personal property held as an investment
• Lump sum receipts or one-time receipts
• Mortgage or deed of trust held by an applicant
• Assets disposed of for less than fair market value.
Assets Do Not Include:
• Necessary personal property (clothing, furniture,
cars, wedding ring, vehicles specially equipped for
persons with disabilities)
• Interests in Indian trust land
• Term life insurance policies
• Equity in the cooperative unit in which the family
lives
• Assets that are part of an active business
• Assets that are not effectively owned by the
applicant
or are held in an individual’s name but:
• The assets and any income they earn accrue to
the benefit of someone else who is not a member
of the household, and
• that other person is responsible for income taxes
incurred on income generated by the assets

•

•

Assets that are not accessible to the applicant and
provide no income to the applicant (Example: A
battered spouse owns a house with her husband.
Due to the domestic situation, she receives no
income from the asset and cannot convert the asset
to cash.)
Assets disposed of for less than fair market value as

2

a result of:
• Foreclosure
• Bankruptcy
• Divorce or separation agreement if the applicant
or resident receives important consideration not
necessarily in dollars.
Exclusions from Annual Income:
• Income from the employment of children (including
foster children) under the age of 18
• Payment received for the care of foster children or
foster adults (usually persons with disabilities,
unrelated to the tenant family, who are unable to live
alone
• Lump-sum additions to family assets, such as
inheritances, insurance payments (including
payments under health and accident insurance and
worker’s compensation), capital gains and settlement
for personal or property losses
• Amounts received by the family that are specifically
for, or in reimbursement of, the cost of medical
expenses for any family member
• Income of a live-in aide
• The full amount of student financial assistance either
paid directly to the student or to the educational
institution
• The special pay to a family member serving in the
Armed Forces who is exposed to hostile fire
• Amounts received under training programs funded
by HUD
• Amounts received by a person with a disability that
are disregarded for a limited time for purposes of
Supplemental Security Income eligibility and
benefits because they are set aside for use under a
Plan to Attain Self-Sufficiency (PASS)
• Amounts received by a participant in other publicly
assisted programs which are specifically for or in
reimbursement of out-of-pocket expenses incurred
(special equipment, clothing, transportation, child
care, etc.) and which are made solely to allow
participation in a specific program
• Resident service stipend (not to exceed $200 per
month)
• Incremental earnings and benefits resulting to any
family member from participation in qualifying State
or local employment training programs and training
of a family member as resident management staff
• Temporary, non-recurring or sporadic income
(including gifts)

•

•
•
•

•
•

Reparation payments paid by a foreign government
pursuant to claims filed under the laws of that
government by persons who were persecuted during
the Nazi era
Earnings in excess of $480 for each full time student
18 years old or older (excluding head of household,
co-head or spouse)
Adoption assistance payments in excess of $480 per
adopted child
Deferred periodic payments of supplemental security
income and social security benefits that are received
in a lump sum amount or in prospective monthly
amounts
Amounts received by the family in the form of
refunds or rebates under State of local law for
property taxes paid on the dwelling unit
Amounts paid by a State agency to a family with a
member who has a developmental disability and is
living at home to offset the cost of services and
equipment needed to keep the developmentally
disabled family member at home

Federally Mandated Exclusions:
• Value of the allotment provided to an eligible
household under the Food Stamp Act of 1977
• Payments to Volunteers under the Domestic
Volunteer Services Act of 1973
• Payments received under the Alaska Native Claims
Settlement Act
• Income derived from certain submarginal land of the
US that is held in trust for certain Indian Tribes
• Payments or allowances made under the Department
of Health and Human Services’ Low-Income Home
Energy Assistance Program
• Payments received under programs funded in whole
or in part under the Job Training Partnership Act
• Income derived from the disposition of funds to the
Grand River Band of Ottawa Indians
• The first $2000 of per capita shares received from
judgment funds awarded by the Indian Claims
Commission or the US. Claims Court, the interests
of individual Indians in trust or restricted lands,
including the first $2000 per year of income
received by individual Indians from funds derived
from interests held in such trust or restricted lands
• Amounts of scholarships funded under Title IV of
the Higher Education Act of 1965, including awards
under the Federal work-study program or under the
Bureau of Indian Affairs student assistance programs

3

•
•

•
•

•
•

•
•
•

•

Payments received from programs funded under
Title V of the Older Americans Act of 1985
Payments received on or after January 1, 1989, from
the Agent Orange Settlement Fund or any other fund
established pursuant to the settlement in In Re
Agent-product liability litigation
Payments received under the Maine Indian Claims
Settlement Act of 1980
The value of any child care provided or arranged (or
any amount received as payment for such care or
reimbursement for costs incurred for such care)
under the Child Care and Development Block Grant
Act of 1990
Earned income tax credit (EITC) refund payments
on or after January 1, 1991
Payments by the Indian Claims Commission to the
Confederated Tribes and Bands of Yakima Indian
Nation or the Apache Tribe of Mescalero
Reservation
Allowance, earnings and payments to AmeriCorps
participants under the National and Community
Service Act of 1990
Any allowance paid under the provisions of
38U.S.C. 1805 to a child suffering from spina bifida
who is the child of a Vietnam veteran
Any amount of crime victim compensation (under
the Victims of Crime Act) received through crime
victim assistance (or payment or reimbursement of
the cost of such assistance) as determined under the
Victims of Crime Act because of the commission of
a crime against the applicant under the Victims of
Crime Act
Allowances, earnings and payments to individuals
participating under the Workforce Investment Act of
1998.

Deductions:
•
•
•
•

•

•

$480 for each dependent including full time students
or persons with a disability
$400 for any elderly family or disabled family
Unreimbursed medical expenses of any elderly
family or disabled family that total more than 3% of
Annual Income
Unreimbursed reasonable attendant care and
auxiliary apparatus expenses for disabled family
member(s) to allow family member(s) to work that
total more than 3% of Annual Income
If an elderly family has both unreimbursed medical
expenses and disability assistance expenses, the
family’s 3% of income expenditure is applied only
one time
Any reasonable child care expenses for children
under age 13 necessary to enable a member of the
family to be employed or to further his or her
education.

Reference Materials
Regulations:
• General HUD Program Requirements;24 CFR Part 5
• Determining Adjusted Income in HUD Programs
Serving Persons with Disabilities; Requiring
Mandatory Deductions for Certain Expenses; and
Disallowance for Earned Income, 65 FR 4608,
August 21, 2000; 24 CFR Parts 5, 92, et al.
Handbook:
• 4350.3, Occupancy Requirements of Subsidized
Multifamily Housing Programs
Notices:
• “Federally Mandated Exclusions” Notice 66 FR
4669, April 20, 2001
For More Information:
Find out more about HUD’s programs on HUD’s
Internet homepage at http://www.hud.gov

4

OAs’ Responsibilities:

FACT SHEET
For HUD ASSISTED RESIDENTS

Rent Supplement
“HOW YOUR RENT IS
DETERMINED”
Office of Housing
January 2002

This Fact Sheet is a general guide to inform the
Owner/Management Agents (OA) and HUDassisted residents of the responsibilities and rights
regarding income disclosure and verification.

•
•
•
•
•
•
•
•
•

Obtain accurate income information
Verify resident income
Ensure residents receive the exclusions and
deductions to which they are entitled
Accurately calculate Tenant Rent
Provide tenants a copy of lease agreement and
income and rent determinations Recalculate rent
when changes in family composition are reported
Recalculate rent when resident income decreases
Recalculate rent when resident income increases by
$200 or more per month
Provide information on OA policies upon request
Notify residents of any changes in requirements or
practices for reporting income or determining rent

Residents’ Responsibilities:
•
•
•
•
•
•

Provide accurate family composition information
Report all income
Keep copies of papers, forms, and receipts which
document income and expenses
Report changes in family composition and income
occurring between annual recertifications
Sign consent forms for income verification
Follow lease requirements and house rules

Income Determinations
Why Determining Income and Rent
Correctly is Important
Department of Housing and Urban Development studies
show that many resident families pay incorrect rent. The
main causes of this problem are:
•
•

Under-reporting of income by resident families, and
OAs not granting exclusions and deductions to
which resident families are entitled.

OAs and residents all have a responsibility in ensuring
that the correct rent is paid.

A family’s anticipated gross income determines not only
eligibility for assistance, but also determines the rent a
family will pay and the subsidy required. The
anticipated income, subject to exclusions and deductions
the family will receive during the next twelve (12)
months, is used to determine the family’s rent.
What is Annual Income?
Gross Income – Income Exclusions = Annual Income
What is Adjusted Income?
Annual Income – Deductions = Adjusted Income

Determining Tenant Rent
Rent Supplement Rent Formula:
The rent a family will pay is the higher of the following
amounts:
• 30% of the family’s monthly adjusted income
• 30% of Gross Rent.
If this is a move-in or initial certification, the family is
only eligible if their total tenant payment is less than
90% of Gross Rent.

Income and Assets
HUD assisted residents are required to report all income
from all sources to the Owner or Agent (OA).
Exclusions to income and deductions are part of the
tenant rent process.
When determining the amount of income from assets to
be included in annual income, the actual income derived
from the assets is included except when the cash value of
all of the assets is in excess of $5,000, then the amount
included in annual income is the higher of 2% of the
total assets or the actual income derived from the assets.
Annual Income Includes:
• Full amount (before payroll deductions) of wages
and salaries, overtime pay, commissions, fees, tips
and bonuses and other compensation for personal
services
• Net income from the operation of a business or
profession
• Interest, dividends and other net income of any kind
from real or personal property (See Assets
Include/Assets Do Not Include below)
• Full amount of periodic amounts received from
Social Security, annuities, insurance policies,
retirement funds, pensions, disability or death
benefits and other similar types of periodic receipts,
including lump-sum amount or prospective monthly
amounts for the delayed start of a periodic amount
• Payments in lieu of earnings, such as unemployment
and disability compensation, worker’s compensation
and severance pay
• Welfare assistance
• Periodic and determinable allowances, such as
alimony and child support payments and regular
contributions or gifts received from organizations or
from persons not residing in the dwelling

•

All regular pay, special pay and allowances of a
member of the Armed Forces (except for special pay
for exposure to hostile fire)

Assets Include:
• Stocks, bonds, Treasury bills, certificates of deposit,
money market accounts
• Individual retirement and Keogh accounts
• Retirement and pension funds
• Cash held in savings and checking accounts, safe
deposit boxes, homes, etc.
• Cash value of whole life insurance policies available
to the individual before death
• Equity in rental property and other capital
investments
• Personal property held as an investment
• Lump sum receipts or one-time receipts
• Mortgage or deed of trust held by an applicant
• Assets disposed of for less than fair market value.
Assets Do Not Include:
• Necessary personal property (clothing, furniture,
cars, wedding ring, vehicles specially equipped for
persons with disabilities)
• Interests in Indian trust land
• Term life insurance policies
• Equity in the cooperative unit in which the family
lives
• Assets that are part of an active business
• Assets that are not effectively owned by the
applicant or are held in an individual’s name but:
• The assets and any income they earn accrue to
the benefit of someone else who is not a member
of the household, and
• that other person is responsible for income taxes
incurred on income generated by the assets
• Assets that are not accessible to the applicant and
provide no income to the applicant (Example: A
battered spouse owns a house with her husband.
Due to the domestic situation, she receives no
income from the asset and cannot convert the asset
to cash.)
• Assets disposed of for less than fair market value as
a result of:
• Foreclosure
• Bankruptcy
• Divorce or separation agreement if the applicant
or resident receives important consideration not
necessarily in dollars.

2

Exclusions from Annual Income:
• Income from the employment of children (including
foster children) under the age of 18
• Payment received for the care of foster children or
foster adults (usually persons with disabilities,
unrelated to the tenant family, who are unable to live
alone
• Lump-sum additions to family assets, such as
inheritances, insurance payments (including
payments under health and accident insurance and
worker’s compensation), capital gains and settlement
for personal or property losses
• Amounts received by the family that are specifically
for, or in reimbursement of, the cost of medical
expenses for any family member
• Income of a live-in aide
• The full amount of student financial assistance either
paid directly to the student or to the educational
institution
• The special pay to a family member serving in the
Armed Forces who is exposed to hostile fire
• Amounts received under training programs funded
by HUD
• Amounts received by a person with a disability that
are disregarded for a limited time for purposes of
Supplemental Security Income eligibility and
benefits because they are set aside for use under a
Plan to Attain Self-Sufficiency (PASS)
• Amounts received by a participant in other publicly
assisted programs which are specifically for or in
reimbursement of out-of-pocket expenses incurred
(special equipment, clothing, transportation, child
care, etc.) and which are made solely to allow
participation in a specific program
• Resident service stipend (not to exceed $200 per
month)
• Incremental earnings and benefits resulting to any
family member from participation in qualifying State
or local employment training programs and training
of a family member as resident management staff
• Temporary, non-recurring or sporadic income
(including gifts)
• Reparation payments paid by a foreign government
pursuant to claims filed under the laws of that
government by persons who were persecuted during
the Nazi era
• Earnings in excess of $480 for each full time student
18 years old or older (excluding head of household,
co-head or spouse)

•
•

•
•

Adoption assistance payments in excess of $480 per
adopted child
Deferred periodic payments of supplemental security
income and social security benefits that are received
in a lump sum amount or in prospective monthly
amounts
Amounts received by the family in the form of
refunds or rebates under State of local law for
property taxes paid on the dwelling unit
Amounts paid by a State agency to a family with a
member who has a developmental disability and is
living at home to offset the cost of services and
equipment needed to keep the developmentally
disabled family member at home

Federally Mandated Exclusions:
• Value of the allotment provided to an eligible
household under the Food Stamp Act of 1977
• Payments to Volunteers under the Domestic
Volunteer Services Act of 1973
• Payments received under the Alaska Native Claims
Settlement Act
• Income derived from certain submarginal land of the
US that is held in trust for certain Indian Tribes
• Payments or allowances made under the Department
of Health and Human Services’ Low-Income Home
Energy Assistance Program
• Payments received under programs funded in whole
or in part under the Job Training Partnership Act
• Income derived from the disposition of funds to the
Grand River Band of Ottawa Indians
• The first $2000 of per capita shares received from
judgment funds awarded by the Indian Claims
Commission or the US. Claims Court, the interests
of individual Indians in trust or restricted lands,
including the first $2000 per year of income
received by individual Indians from funds derived
from interests held in such trust or restricted lands
• Amounts of scholarships funded under Title IV of
the Higher Education Act of 1965, including awards
under the Federal work-study program or under the
Bureau of Indian Affairs student assistance programs
• Payments received from programs funded under
Title V of the Older Americans Act of 1985
• Payments received on or after January 1, 1989, from
the Agent Orange Settlement Fund or any other fund
established pursuant to the settlement in In Re
Agent-product liability litigation

3

•
•

•
•

•
•
•

•

Payments received under the Maine Indian Claims
Settlement Act of 1980
The value of any child care provided or arranged (or
any amount received as payment for such care or
reimbursement for costs incurred for such care)
under the Child Care and Development Block Grant
Act of 1990
Earned income tax credit (EITC) refund payments
on or after January 1, 1991
Payments by the Indian Claims Commission to the
Confederated Tribes and Bands of Yakima Indian
Nation or the Apache Tribe of Mescalero
Reservation
Allowance, earnings and payments to AmeriCorps
participants under the National and Community
Service Act of 1990
Any allowance paid under the provisions of
38U.S.C. 1805 to a child suffering from spina bifida
who is the child of a Vietnam veteran
Any amount of crime victim compensation (under
the Victims of Crime Act) received through crime
victim assistance (or payment or reimbursement of
the cost of such assistance) as determined under the
Victims of Crime Act because of the commission of
a crime against the applicant under the Victims of
Crime Act
Allowances, earnings and payments to individuals
participating under the Workforce Investment Act of
1998.

family to be employed or to further his or her
education.

Reference Materials
Regulations:
• General HUD Program Requirements;24 CFR Part 5
• Determining Adjusted Income in HUD Programs
Serving Persons with Disabilities; Requiring
Mandatory Deductions for Certain Expenses; and
Disallowance for Earned Income, 65 FR 4608,
August 21, 2000; 24 CFR Parts 5, 92, et al.
Handbook:
• 4350.3, Occupancy Requirements of Subsidized
Multifamily Housing Programs
Notices:
• “Federally Mandated Exclusions” Notice 66 FR
4669, April 20, 2001
For More Information:
Find out more about HUD’s programs on HUD’s
Internet homepage at http://www.hud.gov

Deductions:
•
•
•

•

•

•

$480 for each dependent including full time students
or persons with a disability
$400 for any elderly family or disabled family
Unreimbursed medical expenses of any elderly
family or disabled family that total more than 3% of
Annual Income. Family income expenditure is
applied only one time
Unreimbursed reasonable attendant care and
auxiliary apparatus expenses for disabled family
member(s) to allow family member(s) to work that
total more than 3% of Annual Income
If an elderly family has both unreimbursed medical
expenses and disability assistance expenses, the
family’s 3% of income expenditure is applied only
one time
Any reasonable child care expenses for children
under age 13 necessary to enable a member of the

4

OAs’ Responsibilities:

FACT SHEET
For HUD ASSISTED RESIDENTS
Section 202/162 – Project Assistance
Contract (PAC)
Section 202/811 – Project Rental
Assistance Contract (PRAC)

“HOW YOUR RENT IS
DETERMINED”

•
•
•
•
•
•
•
•

Residents’ Responsibilities:
•
•
•

Office of Housing

•

January 2002

•
•

This Fact Sheet is a general guide to inform the
Owner/Management Agents (OA) and HUDassisted residents of the responsibilities and rights
regarding income disclosure and verification.

Why Determining Income and Rent
Correctly is Important

Obtain accurate income information
Verify resident income
Ensure residents receive the exclusions and
deductions to which they are entitled
Accurately calculate Tenant Rent
Provide tenants a copy of lease agreement and
income and rent determinations
Recalculate rent when changes in family
composition and decreases or increases in income
are reported by $200 more per month
Provide information on OA policies upon request
Notify residents of any changes in requirements or
practices for reporting income or determining rent

Provide accurate family composition information
Report all income
Keep copies of papers, forms, and receipts which
document income and expenses
Report changes in family composition and income
occurring between annual recertifications
Sign consent forms for income verification
Follow lease requirements and house rules

Income Determinations
A family’s anticipated gross income determines not only
eligibility for assistance, but also determines the rent a
family will pay and the subsidy required. The
anticipated income, subject to exclusions and deductions
the family will receive during the next twelve (12)
months, is used to determine the family’s rent.
What is Annual Income?
Gross Income – Income Exclusions = Annual Income

Department of Housing and Urban Development studies
show that many resident families pay incorrect rent. The
main causes of this problem are:
•
•

Under-reporting of income by resident families, and
OAs not granting exclusions and deductions to
which resident families are entitled.

OAs and residents all have a responsibility in ensuring
that the correct rent is paid.

What is Adjusted Income?
Annual Income – Deductions = Adjusted Income

Determining Tenant Rent
The rent a family will pay is the highest of the following
amounts:
• 30% of the family’s monthly adjusted income
• 10% of the family’s monthly income
• Welfare rent or welfare payment from agency
to assist family in paying housing costs.
Note: An owner may admit an applicant to the PAC
program only if the Total Tenant Payment is less than

the gross rent. This note does not apply to the PRAC
program. In some instances under the PRAC program a
tenant’s Total Tenant Payment will exceed the PRAC
operating rent (gross rent).

Income and Assets
HUD assisted residents are required to report all income
from all sources to the Owner or Agent (OA).
Exclusions to income and deductions are part of the
tenant rent process.
When determining the amount of income from assets to
be included in annual income, the actual income derived
from the assets is included except when the cash value of
all of the assets is in excess of $5,000, then the amount
included in annual income is the higher of 2% of the
total assets or the actual income derived from the assets.
Annual Income Includes:
• Full amount (before payroll deductions) of wages
and salaries, overtime pay, commissions, fees, tips
and bonuses and other compensation for personal
services
• Net income from the operation of a business or
profession
• Interest, dividends and other net income of any kind
from real or personal property (See Assets
Include/Assets Do Not Include below)
• Full amount of periodic amounts received from
Social Security, annuities, insurance policies,
retirement funds, pensions, disability or death
benefits and other similar types of periodic receipts,
including lump-sum amount or prospective monthly
amounts for the delayed start of a periodic amount
• Payments in lieu of earnings, such as unemployment
and disability compensation, worker’s compensation
and severance pay
• Welfare assistance
• Periodic and determinable allowances, such as
alimony and child support payments and regular
contributions or gifts received from organizations or
from persons not residing in the dwelling
• All regular pay, special pay and allowances of a
member of the Armed Forces (except for special pay
for exposure to hostile fire)

Assets Include:
• Stocks, bonds, Treasury bills, certificates of deposit,
money market accounts
• Individual retirement and Keogh accounts
• Retirement and pension funds
• Cash held in savings and checking accounts, safe
deposit boxes, homes, etc.
• Cash value of whole life insurance policies available
to the individual before death
• Equity in rental property and other capital
investments
• Personal property held as an investment
• Lump sum receipts or one-time receipts
• Mortgage or deed of trust held by an applicant
• Assets disposed of for less than fair market value.
Assets Do Not Include:
• Necessary personal property (clothing, furniture,
cars, wedding ring, vehicles specially equipped for
persons with disabilities)
• Interests in Indian trust land
• Term life insurance policies
• Equity in the cooperative unit in which the family
lives
• Assets that are part of an active business
• Assets that are not effectively owned by the
applicant
or are held in an individual’s name but:
• The assets and any income they earn accrue to
the benefit of someone else who is not a member
of the household, and
• that other person is responsible for income taxes
incurred on income generated by the assets
• Assets that are not accessible to the applicant and
provide no income to the applicant (Example: A
battered spouse owns a house with her husband.
Due to the domestic situation, she receives no
income from the asset and cannot convert the asset
to cash.)
• Assets disposed of for less than fair market value as
a result of:
• Foreclosure
• Bankruptcy
• Divorce or separation agreement if the applicant
or resident receives important consideration not
necessarily in dollars.

2

Exclusions from Annual Income:
• Income from the employment of children (including
foster children) under the age of 18
• Payment received for the care of foster children or
foster adults (usually persons with disabilities,
unrelated to the tenant family, who are unable to live
alone
• Lump-sum additions to family assets, such as
inheritances, insurance payments (including
payments under health and accident insurance and
worker’s compensation), capital gains and settlement
for personal or property losses
• Amounts received by the family that are specifically
for, or in reimbursement of, the cost of medical
expenses for any family member
• Income of a live-in aide
• The full amount of student financial assistance either
paid directly to the student or to the educational
institution
• The special pay to a family member serving in the
Armed Forces who is exposed to hostile fire
• Amounts received under training programs funded
by HUD
• Amounts received by a person with a disability that
are disregarded for a limited time for purposes of
Supplemental Security Income eligibility and
benefits because they are set aside for use under a
Plan to Attain Self-Sufficiency (PASS)
• Amounts received by a participant in other publicly
assisted programs which are specifically for or in
reimbursement of out-of-pocket expenses incurred
(special equipment, clothing, transportation, child
care, etc.) and which are made solely to allow
participation in a specific program
• Resident service stipend (not to exceed $200 per
month)
• Incremental earnings and benefits resulting to any
family member from participation in qualifying State
or local employment training programs and training
of a family member as resident management staff
• Temporary, non-recurring or sporadic income
(including gifts)
• Reparation payments paid by a foreign government
pursuant to claims filed under the laws of that
government by persons who were persecuted during
the Nazi era
• Earnings in excess of $480 for each full time student
18 years old or older (excluding head of household,
co-head or spouse)
• Adoption assistance payments in excess of $480 per
adopted child
• Deferred periodic payments of supplemental security
income and social security benefits that are received

•
•

in a lump sum amount or in prospective monthly
amounts
Amounts received by the family in the form of
refunds or rebates under State of local law for
property taxes paid on the dwelling unit
Amounts paid by a State agency to a family with a
member who has a developmental disability and is
living at home to offset the cost of services and
equipment needed to keep the developmentally
disabled family member at home

Federally Mandated Exclusions:
• Value of the allotment provided to an eligible
household under the Food Stamp Act of 1977
• Payments to Volunteers under the Domestic
Volunteer Services Act of 1973
• Payments received under the Alaska Native Claims
Settlement Act
• Income derived from certain submarginal land of the
US that is held in trust for certain Indian Tribes
• Payments or allowances made under the Department
of Health and Human Services’ Low-Income Home
Energy Assistance Program
• Payments received under programs funded in whole
or in part under the Job Training Partnership Act
• Income derived from the disposition of funds to the
Grand River Band of Ottawa Indians
• The first $2000 of per capita shares received from
judgment funds awarded by the Indian Claims
Commission or the US. Claims Court, the interests
of individual Indians in trust or restricted lands,
including the first $2000 per year of income
received by individual Indians from funds derived
from interests held in such trust or restricted lands
• Amounts of scholarships funded under Title IV of
the Higher Education Act of 1965, including awards
under the Federal work-study program or under the
Bureau of Indian Affairs student assistance programs
• Payments received from programs funded under
Title V of the Older Americans Act of 1985
• Payments received on or after January 1, 1989, from
the Agent Orange Settlement Fund or any other fund
established pursuant to the settlement in In Re
Agent-product liability litigation
• Payments received under the Maine Indian Claims
Settlement Act of 1980
• The value of any child care provided or arranged (or
any amount received as payment for such care or
reimbursement for costs incurred for such care)
under the Child Care and Development Block Grant
Act of 1990
• Earned income tax credit (EITC) refund payments
on or after January 1, 1991
3

•

•
•
•

•

Payments by the Indian Claims Commission to the
Confederated Tribes and Bands of Yakima Indian
Nation or the Apache Tribe of Mescalero
Reservation
Allowance, earnings and payments to AmeriCorps
participants under the National and Community
Service Act of 1990
Any allowance paid under the provisions of
38U.S.C. 1805 to a child suffering from spina bifida
who is the child of a Vietnam veteran
Any amount of crime victim compensation (under
the Victims of Crime Act) received through crime
victim assistance (or payment or reimbursement of
the cost of such assistance) as determined under the
Victims of Crime Act because of the commission of
a crime against the applicant under the Victims of
Crime Act
Allowances, earnings and payments to individuals
participating under the Workforce Investment Act of
1998

Deductions:
•
•
•

•

•

•

Reference Materials
Regulations:
• General HUD Program Requirements;24 CFR Part 5
and CFR 24 Part 891.
• Determining Adjusted Income in HUD Programs
Serving Persons with Disabilities; Requiring
Mandatory Deductions for Certain Expenses; and
Disallowance for Earned Income, 65 FR 4608,
August 21, 2000; 24 CFR Parts 5, 92, et al.
Handbook:
• 4350.3, Occupancy Requirements of Subsidized
Multifamily Housing Programs
Notices:
• “Federally Mandated Exclusions” Notice 66 FR
4669, April 20, 2001
For More Information:
Find out more about HUD’s programs on HUD’s
Internet homepage at http://www.hud.gov

$480 for each dependent including full time students
or persons with a disability
$400 for any elderly family or disabled family
Unreimbursed medical expenses of any elderly
family or disabled family that total more than 3% of
Annual Income the expenditure is applied only one
time
Unreimbursed reasonable attendant care and
auxiliary apparatus expenses for disabled family
member(s) to allow family member(s) to work that
total more than 3% of Annual Income
If an elderly family has both unreimbursed medical
expenses and disability assistance expenses, the
family’s 3% of income expenditure is applied only
one time
Any reasonable child care expenses for children
under age 13 necessary to enable a member of the
family to be employed or to further his or her
education.

4

•

FACT SHEET
For HUD ASSISTED RESIDENTS

•
•

Section 236

•
•

“HOW YOUR RENT IS
DETERMINED”
Office of Housing
January 2002

This Fact Sheet is a general guide to inform the
Owner/Management Agents (OA) and HUDassisted residents of the responsibilities and rights
regarding income disclosure and verification.

Why Determining Income and Rent
Correctly is Important
Department of Housing and Urban Development studies
show that many resident families pay incorrect rent. The
main causes of this problem are:
•
•

Under-reporting of income by resident families, and
OAs not granting exclusions and deductions to
which resident families are entitled.

OAs and residents all have a responsibility in ensuring
that the correct rent is paid.

OAs’ Responsibilities:
•
•
•
•

•

Obtain accurate income information
Verify resident income
Ensure residents receive the exclusions and
deductions to which they are entitled
Accurately calculate Tenant Rent

Provide tenants a copy of lease agreement and
income and rent determinations
Recalculate rent when changes in family
composition are reported
Recalculate rent when resident income decreases
Recalculate rent when resident income increases by
$200 or more per month
Provide information on OA policies upon request
Notify residents of any changes in requirements or
practices for reporting income or determining rent

Residents’ Responsibilities:
•
•
•
•
•
•

Provide accurate family composition information
Report all income
Keep copies of papers, forms, and receipts which
document income and expenses
Report changes in family composition and income
occurring between annual recertifications
Sign consent forms for income verification
Follow lease requirements and house rules

Income Determinations
A family’s anticipated gross income determines not only
eligibility, but also determines the rent a family will pay.
The anticipated income, subject to exclusions and
deductions the family will receive during the next twelve
(12) months, is used to determine the family’s rent.
What is Annual Income?
Gross Income – Income Exclusions = Annual Income
What is Adjusted Income?
Annual Income – Deductions = Adjusted Income

Determining Tenant Rent
Section 236 Rent Formulas:
All Section 236 Projects have a minimum rent (Basic
Rent) and a maximum rent (Market Rent).
Section 236 with NO Utility Allowance; the higher of:
• 30% of the family’s monthly adjusted income
• Basic Rent
• But not more than Market Rent

Section 236 WITH Utility Allowance; the highest of:
• 30% of the family’s monthly adjusted income less
the Utility Allowance
• 25% of the family’s monthly adjusted income
• Basic Rent
• But not more than Market Rent
A Utility Allowance is approved by HUD when the cost
of all or a portion of the utilities (except telephone) is
not included in the unit rent and payment for the utilities
is the responsibility of the family occupying the unit.
The utility allowance is not meant to pay all actual utility
costs, but rather it is an allowance provided to the family
to assist them in payment of their utility expenses.

Income and Assets
HUD assisted residents are required to report all income
from all sources to the Owner or Agent (OA).
Exclusions to income and deductions are part of the
tenant rent process.
When determining the amount of income from assets to
be included in annual income, the actual income derived
from the assets is included except when the cash value of
all of the assets is in excess of $5,000, then the amount
included in annual income is the higher of 2% of the
total assets or the actual income derived from the assets.
Annual Income Includes:
• Full amount (before payroll deductions) of wages
and salaries, overtime pay, commissions, fees, tips
and bonuses and other compensation for personal
services
• Net income from the operation of a business or
profession
• Interest, dividends and other net income of any kind
from real or personal property (See Assets
Include/Assets Do Not Include below)
• Full amount of periodic amounts received from
Social Security, annuities, insurance policies,
retirement funds, pensions, disability or death
benefits and other similar types of periodic receipts,
including lump-sum amount or prospective monthly
amounts for the delayed start of a periodic amount
• Payments in lieu of earnings, such as unemployment
and disability compensation, worker’s compensation
and severance pay
• Welfare assistance

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Periodic and determinable allowances, such as
alimony and child support payments and regular
contributions or gifts received from organizations or
from persons not residing in the dwelling
All regular pay, special pay and allowances of a
member of the Armed Forces (except for special pay
for exposure to hostile fire)

Assets Include:
• Stocks, bonds, Treasury bills, certificates of deposit,
money market accounts
• Individual retirement and Keogh accounts
• Retirement and pension funds
• Cash held in savings and checking accounts, safe
deposit boxes, homes, etc.
• Cash value of whole life insurance policies available
to the individual before death
• Equity in rental property and other capital
investments
• Personal property held as an investment
• Lump sum receipts or one-time receipts
• Mortgage or deed of trust held by an applicant
• Assets disposed of for less than fair market value.
Assets Do Not Include:
• Necessary personal property (clothing, furniture,
cars, wedding ring, vehicles specially equipped for
persons with disabilities)
• Interests in Indian trust land
• Term life insurance policies
• Equity in the cooperative unit in which the family
lives
• Assets that are part of an active business
• Assets that are not effectively owned by the
applicant
or are held in an individual’s name but:
• The assets and any income they earn accrue to
the benefit of someone else who is not a member
of the household, and
• that other person is responsible for income taxes
incurred on income generated by the assets
• Assets that are not accessible to the applicant and
provide no income to the applicant (Example: A
battered spouse owns a house with her husband.
Due to the domestic situation, she receives no
income from the asset and cannot convert the asset
to cash.)
• Assets disposed of for less than fair market value as
a result of:

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Foreclosure
Bankruptcy
Divorce or separation agreement if the applicant
or resident receives important consideration not
necessarily in dollars.

Exclusions from Annual Income:
• Income from the employment of children (including
foster children) under the age of 18
• Payment received for the care of foster children or
foster adults (usually persons with disabilities,
unrelated to the tenant family, who are unable to live
alone
• Lump-sum additions to family assets, such as
inheritances, insurance payments (including
payments under health and accident insurance and
worker’s compensation), capital gains and settlement
for personal or property losses
• Amounts received by the family that are specifically
for, or in reimbursement of, the cost of medical
expenses for any family member
• Income of a live-in aide
• The full amount of student financial assistance either
paid directly to the student or to the educational
institution
• The special pay to a family member serving in the
Armed Forces who is exposed to hostile fire
• Amounts received under training programs funded
by HUD
• Amounts received by a person with a disability that
are disregarded for a limited time for purposes of
Supplemental Security Income eligibility and
benefits because they are set aside for use under a
Plan to Attain Self-Sufficiency (PASS)
• Amounts received by a participant in other publicly
assisted programs which are specifically for or in
reimbursement of out-of-pocket expenses incurred
(special equipment, clothing, transportation, child
care, etc.) and which are made solely to allow
participation in a specific program
• Resident service stipend (not to exceed $200 per
month)
• Incremental earnings and benefits resulting to any
family member from participation in qualifying State
or local employment training programs and training
of a family member as resident management staff
• Temporary, non-recurring or sporadic income
(including gifts)

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Reparation payments paid by a foreign government
pursuant to claims filed under the laws of that
government by persons who were persecuted during
the Nazi era
Earnings in excess of $480 for each full time student
18 years old or older (excluding head of household,
co-head or spouse)
Adoption assistance payments in excess of $480 per
adopted child
Deferred periodic payments of supplemental security
income and social security benefits that are received
in a lump sum amount or in prospective monthly
amounts
Amounts received by the family in the form of
refunds or rebates under State of local law for
property taxes paid on the dwelling unit
Amounts paid by a State agency to a family with a
member who has a developmental disability and is
living at home to offset the cost of services and
equipment needed to keep the developmentally
disabled family member at home

Federally Mandated Exclusions:
• Value of the allotment provided to an eligible
household under the Food Stamp Act of 1977
• Payments to Volunteers under the Domestic
Volunteer Services Act of 1973
• Payments received under the Alaska Native Claims
Settlement Act
• Income derived from certain submarginal land of the
US that is held in trust for certain Indian Tribes
• Payments or allowances made under the Department
of Health and Human Services’ Low-Income Home
Energy Assistance Program
• Payments received under programs funded in whole
or in part under the Job Training Partnership Act
• Income derived from the disposition of funds to the
Grand River Band of Ottawa Indians
• The first $2000 of per capita shares received from
judgment funds awarded by the Indian Claims
Commission or the US. Claims Court, the interests
of individual Indians in trust or restricted lands,
including the first $2000 per year of income
received by individual Indians from funds derived
from interests held in such trust or restricted lands
• Amounts of scholarships funded under Title IV of
the Higher Education Act of 1965, including awards
under the Federal work-study program or under the
Bureau of Indian Affairs student assistance programs

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Payments received from programs funded under
Title V of the Older Americans Act of 1985
Payments received on or after January 1, 1989, from
the Agent Orange Settlement Fund or any other fund
established pursuant to the settlement in In Re
Agent-product liability litigation
Payments received under the Maine Indian Claims
Settlement Act of 1980
The value of any child care provided or arranged (or
any amount received as payment for such care or
reimbursement for costs incurred for such care)
under the Child Care and Development Block Grant
Act of 1990
Earned income tax credit (EITC) refund payments
on or after January 1, 1991
Payments by the Indian Claims Commission to the
Confederated Tribes and Bands of Yakima Indian
Nation or the Apache Tribe of Mescalero
Reservation
Allowance, earnings and payments to AmeriCorps
participants under the National and Community
Service Act of 1990
Any allowance paid under the provisions of
38U.S.C. 1805 to a child suffering from spina bifida
who is the child of a Vietnam veteran
Any amount of crime victim compensation (under
the Victims of Crime Act) received through crime
victim assistance (or payment or reimbursement of
the cost of such assistance) as determined under the
Victims of Crime Act because of the commission of
a crime against the applicant under the Victims of
Crime Act
Allowances, earnings and payments to individuals
participating under the Workforce Investment Act of
1998.

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If an elderly family has both unreimbursed medical
expenses and disability assistance expenses, the
family’s 3% of income expenditure is applied only
one time.
Any reasonable child care expenses for children
under age 13 necessary to enable a member of the
family to be employed or to further his or her
education.

Reference Materials
Regulations:
• General HUD Program Requirements;24 CFR Part 5
• Determining Adjusted Income in HUD Programs
Serving Persons with Disabilities; Requiring
Mandatory Deductions for Certain Expenses; and
Disallowance for Earned Income, 65 FR 4608,
August 21, 2000; 24 CFR Parts 5, 92, et al.
Handbook:
• 4350.3, Occupancy Requirements of Subsidized
Multifamily Housing Programs
Notices:
• “Federally Mandated Exclusions” Notice 66 FR
4669, April 20, 2001
For More Information:
Find out more about HUD’s programs on HUD’s
Internet homepage at http://www.hud.gov

Deductions:
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$480 for each dependent including full time students
or persons with a disability
$400 for any elderly family or disabled family
Unreimbursed medical expenses of any elderly
family or disabled family that total more than 3% of
Annual Income
Unreimbursed reasonable attendant care and
auxiliary apparatus expenses for disabled family
member(s) to allow family member(s) to work that
total more than 3% of Annual Income

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