HUD 50059 Owner's Certificaiton of Compliance with HUD's Tenant El

Owner’s Certification of Compliance
with HUD’s Tenant Eligibility
and Rent Procedures

U. S. Department of Housing
And Urban Development

NOT for Submission to the Federal Government
Landlord's Official Record of Certification

Office of Housing
Federal Housing Commissioner

OMB Approval Number 2502-0204
(Exp. 12/31/2007)

Section A. Acknowledgements
Read this before you complete and sign this form HUD-50059
Public Reporting Burden. The reporting burden for this collection of information is estimated to average 55 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. Send comments regarding this burden estimate or any other aspect of this collection of
information including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (25020204), Washington, DC 20503. 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 Public Housing
Authority (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, including the Social Security Numbers (SSNs) you, and all other household family members age six (6) years and
older, have and use. Giving the SSNs of all family members age six (6) years and older is mandatory; not providing the SSNs will affect
your eligibility. Failure to provide any information may result in a delay or rejection of your eligibility approval.
Privacy Act Statement. 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).
Tenant(s)' Certification - I/We certify that the information in Sections C, D, and E of this form are true and complete to the best of my/our
knowledge and belief. I/We understand that 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, if I/we furnish false or incomplete information.
Owner's Certification - I certify that this Tenant's eligibility, rent and assistance payments have been computed in accordance with HUD's
regulations and administrative procedures and that all required verifications were obtained.
Warning to Owners and Tenants. By signing this form, you are indicating that you have read the above Privacy Act Statement and are
agreeing with the applicable Certification.
False Claim Statement. Warning: U.S. Code, Title 31, Section 3729, False Claims, provides a civil penalty of not less than $5,000 and
not more than $10,000, plus 3 times the amount of damages for any person who knowingly presents, or causes to be presented, a false or
fraudulent claim; or who knowingly makes, or caused to be used, a false record or statement; or conspires to defraud the Government by
getting a false or fraudulent claim allowed or paid.

Certification Summary from Page 2
Name of Project

Unit Number

Effective Date

Certification Type

Head of Household

Total Tenant Payment

Assistance Payment

Tenant Rent

Tenant Signatures
Head of Household

Date

Other Adult

Date

Spouse / Co-Head

Date

Other Adult

Date

Other Adult

Date

Other Adult

Date

Other Adult

Date

Other Adult

Date

Other Adult

Date

Other Adult

Date

Other Adult

Date

Other Adult

Date

Other Adult

Date

Other Adult

Date

Owner/Agent Signature
Date

Owner/Agent

Anticipated Voucher Date

Check this box if Tenant is unable to sign for a legitimate reason
Previous versions of this form are obsolete.
This form also replaces HUD-50059-D, -E, -F, & -G.

Page 1 of __

form HUD-50059 (04/2005)
HB 4350.3 Rev 1

Owner’s Certification of Compliance
with HUD’s Tenant Eligibility
and Rent Procedures Record for Landlords

U. S. Department of Housing
And Urban Development

For Personal Records ONLY - Not for
Submission to the Federal Government

Office of Housing
Federal Housing Commissioner

(Exp. 12/31/2007)

Section B. Summary Information
1. Project Name

25. Unit Number
26. No. of Bedrooms
27. Building ID
28. Unit Transfer Code
29. Previous Unit No.
30. Security Deposit
31. Market Rent
32. Contract Rent
33. Utility Allowance
34. Gross Rent
35. Conversion Date Code
36. Age 62 at Conversion Indicator
37. Continuous Section 8 Indicator

13. Effective Date
14. Anticipated Voucher Date
15. Next Recertification Date
16. Project Move-In Date
17. Unit Move-In Date
18. Certification Type
19. Action Processed
20. Correction Type
21. Cert. Correction Date
22. Prev. Subsidy Type
23. Previous Housing Code
24. Displacement Status Code

2. Subsidy Type
3. Secondary Subsidy Type
4. Property ID
5. Project Number
6. Contract Number
7. TRACSMail ID
8. Plan of Action Code
9. HUD-Owned Project?
10. Region Code
11. Field Office Code
12. FIPS County Code

Section C. Household Information
38.
No.

39.
Last Name

40.
First Name

41. 42. 43.
MI Rel. Sex

44.
Race

45.
Eth.

46.
Birth
Date

56. Number of Family Members
57. Number of Non-Family Members
58. Number of Dependents
59. Number of Eligible Members

53. Family is Mobility Impaired?
54. Family is Hearing Impaired?
55. Family is Visually Impaired?

49.
50.
51.
52.
Elig. Alien Reg. Age at Work
Code Number
Cert. Codes

66. Previous Effective Date
67. Previous Head ID
68. Previous Head Birth Date

Section E. Asset Information

Section D. Income Information
70.
Income Type Code

48.
ID Code
(SSN)

60. Expected Family Addition - Adoption
61. Expected Family Addition - Pregnancy
62. Expected Family Addition - Foster Children

63. Previous Head Last Name
64. Previous Head First Name
65. Previous Head Middle Initial
69.
Mbr.
No.

47.
Special
Status

71.
Amount

73. Total Employment Income
74. Total Pension Income
75. Total Public Assistance Income
76. Total Other Income
77. Total Non-Asset Income

72.
SSN Benefits
Claim No.

78.
Mbr.
No.

79.
Description

80.
Status

81.
Cash Value

82.
Actual Yearly
Income

83.
Date
Divested

84. Cash Value of Assets
85. Actual Income from Assets
86. HUD Passbook Rate
87. Imputed Income from Assets
88. Asset Income

Section F. Allowances & Rent Calculations
89. Total Annual Income
90. Lower Income Limit
91. Very Low Income Limit
92. Extremely Low Income Limit
93. Current Income Status
94. Eligibility Universe Code
95. Sec. 8 Assist. 1984 Indicator
96. Income Exception Code
97. Police / Security Tenant?
98. Survivor of Qualifier?
99. Household Assistance Status
Previous versions of this form are obsolete.
This form also replaces HUD-50059-D, -E, -F, & -G.

100. Allowance for Dependents
101. Child Care Expense (work)
102. Child Care Expense (school)
103. 3% of Income
104. Disability Expense
105. Disability Allowance
106. Medical Expense
107. Medical Allowance
108. Elderly Household Allowance
109. Total Allowances
110. Adjusted Annual Income
Page 2 of __

111. Total Tenant Payment
112. Tenant Rent
113. Utility Reimbursement
114. Assistance Payment
115. Welfare Rent
116. HCDA percentage
117. Percent Actually Charged
118. Hardship Exemption
119. Waiver Type Code

form HUD-50059 (04/2005)
HB 4350.3 Rev 1

Owner’s Certification of Compliance
with HUD’s Tenant Eligibility
and Rent Procedures Record for Landlords

U. S. Department of Housing
And Urban Development

For Personal Records ONLY - Not for
Submission to the Federal Government

Office of Housing
Federal Housing Commissioner

(Exp. 12/31/2007)

Name of Project

Unit Number

Effective Date

Certification Type

Head of Household

Total Tenant Payment

Assistance Payment

Tenant Rent

Section C. Household Information
38.
No.

39.
Last Name

40.
First Name

41. 42. 43.
MI Rel. Sex

44.
Race

70.
Income Type Code

71.
Amount

Previous versions of this form are obsolete.
This form also replaces HUD-50059-D, -E, -F, & -G.

72.
SSN Benefits
Claim No.

46.
Birth
Date

47.
Special
Status

48.
ID Code
(SSN)

49.
50.
51.
52.
Elig. Alien Reg. Age at Work
Code Number
Cert. Codes

Section E. Asset Information

Section D. Income Information
69.
Mbr.
No.

45.
Eth.

78.
Mbr.
No.

Page __ of __

79.
Description

80.
Status

81.
Cash Value

82.
Actual Yearly
Income

83.
Date
Divested

form HUD-50059 (04/2005)
HB 4350.3 Rev 1