HUD-52671-D Special Claims for Debt Service

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

Special Claims for
Debt Service
Instructions: Follow guidelines in
HUD Handbook 4350.3, Rev. 1,
Chapter 9
Unit number

Unit size
(No. of Bedrooms)

Project name

OMB Approval No. 2502-0182 (04/30/2009)

FHA project no.

Period vacant
From (date)

To (date)

No. of days vacant

Section 8/PAC
contract no.

Amount Claimed
Daily debt ser. attributed
to that unit from HAP con- (column 1 x column 2)
tract (exhibit 2)
(3)

(2)

(1)

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
Previous versions obsolete
Submit an Original and two copies

Claim ID: ___________________
form HUD-52671-D (09/2002)
ref Handbook 4350.3 Rev. 1

This form must be completed so HUD can pay owners an amount to
help the contract remain viable during lengthy vacancy periods.
Regulations require that owners complete this form using statutory formulas for calculating vacancy loss payments.
The statutes requiring the submission are S8, United States
Housing Act (42 U.S.C. 1437 f), Section 202 of the Housing Act of
1959 as amended by Section 801 of the National Affordable Housing Act (12 U.S.C. 1701(g), and Section 811 of the National Affordable
Housing Act (42 U.S.C. 8013). The regulations stipulating these
rules are: 24 CFR 880, 881, 883, 884, 886, and 891. The administrative requirements for these forms are provided in HUD Handbook
4350.3, Rev. 1, Chapter 9.
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 versions obsolete
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 to review accuracy of
funds requested by owner/agent for special claims payments.
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 (09/2002)
ref Handbook 4350.3 Rev. 1