Owner's Certification with HUD Tenant Eligibility and Rent Procedures

4350.3 REV-1

Appendix 5

Appendix 5: Sample Move-In/Move-Out Inspection Form

[Company name]
[Company address]

Property		Resident
Apartment No.	Unit Size	Move-In Inspection Date	Move-Out Inspection Date

Item	Condition		Cost to Correct
	Move-In	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

Item	Condition		Cost to Correct
	Move-In	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

Item	Condition		Cost to Correct
	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

Move-In This unit **is in decent, safe and sanitary condition. ** Any deficiencies identified in this report will be remedied within 30 days of the date the tenant moves into the unit. _______________________________ Manager's Signature I have inspected the apartment and found **this unit to be in decent, safe and sanitary condition. Any deficiencies are 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. _______________________________ Resident's Signature _______________________________ Resident's Signature			Move-Out _______________________________ Manager's Signature Agree with move-out inspection Disagree with move-out inspection If disagree, list specific items of disagreement. _______________________________ Resident's Signature _______________________________ Resident's Signature
By Date Prepared Reviewed Prepared Reviewed				By Date Prepared Reviewed Prepared Reviewed

Public reporting burden - HUD is not requesting approval of any burden hours for the move-in/move-out inspection report since use of move-in/move-out inspection reports are a standard business practice in the housing rental industry. This information is required to obtain benefits and is voluntary. HUD may not collect this information, and you are not required to complete this form, unless it displays a currently valid OMB control number. The owner/management agent and tenant together conduct a move-in/move-out inspection to document the condition of the unit at the time of move-in/move-out. Conducting move-in/move-out inspections are a standard business practice in the housing rental industry and are used for determining damages caused by the tenant during tenancy and allowable deductions from the tenant’s security deposit held by the owner. This information is authorized by 24 CFR 5.703 and 5.705, 886.123, 886.223 cover unit inspections. This information is considered non-sensitive and does no require any special protection.

	By	Date
Prepared	_____	_____
Reviewed	_____	_____
Prepared	_____	_____
Reviewed	_____	_____

HUD Occupancy Handbook 2

Appendix 5: Move-In/Move-Out Inspection Format form HUD-90106

12/2007