HERA Tenant Data Form and Instructions

HUD LIHTC Tenant Data Collection Form

OMB Approval No. xxxx-xxxx (Exp. x/xx/20xx)

HUD LIHTC Tenant Data Collection Form
Initial Certification

Recertification

Effective Date:
Move-in Date:

Other _________

(MM/DD/YYYY)

Property Name:
Address:

PART I - DEVELOPMENT DATA
County: _______________
Unit Number: _______________

_______________________
_______________________

BIN #:
Bedrooms:

_________________
_________________

PART II. HOUSEHOLD COMPOSITION
HH
Mbr #

Last
Name

First
Name

Middle
Initial

Relationship to Head
of Household

Date of Birth

F/T Student

(MM/DD/YYYY)

(Y or N)

Last 4 Digits of
Social Security No.

Race

Ethnicity Disabled?

1
2
3
4
5
6
7
PART III. GROSS ANNUAL INCOME (USE ANNUAL AMOUNTS)
(A)
(B)
(C)
HH Mbr #

Employment or Wages

Soc. Security/Pensions

Public Assistance

(D)
Other Income

TOTALS

Add totals from (A) through (D), above TOTAL INCOME (E):
PART IV. INCOME FROM ASSETS
HH Mbr #

(F)

(G)

(H)

(I)

Type of Asset

C/I

Cash Value of Asset

Annual Income from Asset

TOTALS
Enter Column (H) Total

Passbook Rate

If over $5000

_________________

Enter the greater of the total of column I, or J: Imputed Income

X 2.00%

= (J) Imputed Income

TOTAL INCOME FROM ASSETS (K)

(L) Total Annual Household Income from all Sources [Add (E) + (K)]
PART V. DETERMINATION OF INCOME ELIGIBILITY
RECERTIFICATION ONLY:
TOTAL ANNUAL HOUSEHOLD INCOME

Household Meets

FROM ALL SOURCES:

Income Restriction
at:

From item (L)

Current Income Limit per Family Size:

• 60%

• 50%

• 40%

• 30%

Household Income exceeds 140% at
recertification:
• Yes • No

• ____%

Household Income at Move-in:

U.S. Department of Housing and Urban Development
Previous editions unusable

Current Income Limit x 140%:

Household Size at Move-in:

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HUD LIHTC Tenant Data Collection Form
Revised xxx 2010

HUD LIHTC Tenant Data Collection Form

OMB Approval No. xxxx-xxxx (Exp. x/xx/20xx)

PART VI. RENT
Tenant Paid Rent
Utility Allowance

Rent Assistance:
Other non-optional charges:

GROSS RENT FOR UNIT:
(Tenant paid rent plus Utility Allowance &
other non-optional charges)

Unit Meets Rent Restriction at:
❑ 60%
❑ 40%
❑ 50%
❑ 30%
❑_____%

Maximum Rent Limit for this unit:

PART VII. STUDENT STATUS
*Student Explanation:
ARE ALL OCCUPANTS FULL TIME STUDENTS?

If yes, Enter student explanation*

1 TANF assistance
2 Job Training Program

• Yes

• No

3 Single parent/dependent child
4 Married/joint return

PART VIII. PROGRAM TYPE
Mark the program(s) listed below (a. through e.) for which this household’s unit will be counted toward the property’s occupancy
requirements. Under each program marked, indicate the household’s income status as established by this certification/recertification.
a. Tax Credit •

b. HOME •

c. Tax Exempt •

d. AHDP •

e.
(Name of Program)

See Part V above.

Income Status
• ≤ 50% AMGI
• ≤ 60% AMGI
• ≤ 80% AMGI
• OI**

Income Status
• 50% AMGI
• 60% AMGI
• 80% AMGI
• OI**

Income Status
• ≤ 50% AMGI
• ≤ 80% AMGI
• OI**

Income Status
•
•
•

** Upon recertification, household was determined over-income (OI) according to eligibility requirements of the program(s) marked above.

U.S. Department of Housing and Urban Development
Previous editions unusable

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HUD LIHTC Tenant Data Collection Form
Revised xxx 2010

HUD LIHTC Tenant Data Collection Form

OMB Approval No. xxxx-xxxx (Exp. x/xx/20xx)

Instructions
Part I - Development Data
Check the appropriate box for Initial Certification (move-in), Recertification (annual recertification), or Other. If Other,
designate the purpose of the recertification (i.e., a unit transfer, a change in household composition, or other staterequired recertification).
Move-in Date: Enter the date the tenant has or will take occupancy of the unit.
Effective Date: Enter the effective date of the certification.
Property Name: Enter the name of the development.
County: Enter the county in which the building is located.
BIN #: Enter the Building Identification Number (BIN) assigned to the building (from IRS Form 8609).
Address: Enter the address of the building.
Unit Number: Enter the unit number.
# Bedrooms: Enter the number of bedrooms in the unit.
Part II - Household Composition
Name: List first name, middle initial and last name of all occupants of the unit.
Relationship to Head of Household: Enter each household member’s relationship to the head of household by using one of the
following coded definitions: H – Head of Household; S – Spouse; A – Adult co-tenant; O – Other family member; C – Child; F –
Foster child(ren); L – Live-in caretaker; or N – None of the above.

Race: Enter each household member’s race by using one of the following coded definitions: 1 – White; 2 – Black/African American; 3 –
American Indian/Alaska Native; 4 – Asian; or 5 – Native Hawaiian/Other Pacific Islander.

Ethnicity: Enter each household member’s ethnicity by using one of the following coded definitions: 1 – Hispanic or Latino; 2 – not
Hispanic or Latino.

Date of Birth: Enter each household member’s date of birth in the following format: MM/DD/YYYY.
Student Status: Enter Yes if the household member is a full-time student or No if the household member is not a full-time student.
Last Four Digits of Social Security Number: For each tenant over 18 years of age, enter the last four digits of the social security
number or the last four digits of the alien registration number.

Disabled?: Check yes if any member of the household is disabled according to Fair Housing Act definition for handicap
(disability):
• A physical or mental impairment which substantially limits one or more major life activities; a record of such
an impairment; or being regarded as having such an impairment. For a definition of “physical or mental
impairment” and other terms used in this definition, please see 24 CFR 100.201, available at
http://www.fairhousing.com/index.cfm?method=page.display&pagename=regs_fhr_100-201.
• “Handicap” does not include current, illegal use of or addiction to a controlled substance.
• An individual shall not be considered to have a handicap solely because that individual is a transvestite.
The housing credit agency administering its low-income housing credit program must, to the best of its ability,
provide this disability status information, pursuant to 42 U.S.C. 1437z-8. However, it is the tenant’s voluntary choice
whether to provide such information, and questions to the tenant requesting the information must so state. If the
tenant declines to provide the information, the housing credit agency shall use its best efforts to provide the
information, such as by noting the appearance of a physical disability that is readily apparent and obvious, or by
relying on a past year’s information. For purposes of gathering this information, no questions with respect to the
nature or severity of the disability are appropriate.”
Part III - Annual Income
See HUD Handbook 4350.3 for complete instructions on verifying and calculating income, including acceptable
forms of verification.
From the third party verification forms obtained from each income source, enter the gross amount anticipated to be
received for the twelve months from the effective date of the (re)certification. Complete a separate line for each incomeearning member. List the respective household member number from Part II.
Column (A): Enter the annual amount of wages, salaries, tips, commissions, bonuses and other income from employment; distributed
profits and/or net income from a business.
U.S. Department of Housing and Urban Development
Previous editions unusable

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HUD LIHTC Tenant Data Collection Form
Revised xxx 2010

HUD LIHTC Tenant Data Collection Form

OMB Approval No. xxxx-xxxx (Exp. x/xx/20xx)

Column (B): Enter the annual amount of Social Security, Supplemental Security Income, pensions, military retirement, etc.
Column (C): Enter the annual amount of income received from public assistance (i.e., TANF, general assistance, disability, etc.).
Column (D): Enter the annual amount of alimony, child support, unemployment benefits or any other income regularly received by the
household.

Line (E): Add the totals from columns (A) through (D), above. Enter this amount.
Part IV - Income from Assets
See HUD Handbook 4350.3 for complete instructions on verifying and calculating income from assets, including
acceptable forms of verification.
From the third party verification forms obtained from each asset source, list the gross amount anticipated to be received
during the twelve months from the effective date of the certification. List the respective household member number from
Part II and complete a separate line for each member.
Column (F): List the type of asset (i.e., checking account, savings account, etc.)
Column (G): Enter C (for current, if the family currently owns or holds the asset), or I (for imputed, if the family has disposed of the
asset for less than fair market value within two years of the effective date of (re)certification.

Column (H): Enter the cash value of the respective asset.
Column (I): Enter the anticipated annual income from the asset (i.e., savings account balance multiplied by the annual interest rate).
TOTALS: Add the total of Column (H) and Column (I), respectively.
If the total in Column (H) is greater than $5,000 you must do an imputed calculation of asset income. Enter the Total
Cash Value, multiply by 2% and enter the amount in (J), Imputed Income.
Box (K): Enter the greater of the total in Column (I) or (J).
Box (L): Total Annual Household Income From all Sources. Add (E) and (K) and enter the total.
Part V – Determination of Income Eligibility
Total Annual Household Income from all Sources: Enter the number from item (L).
Current Income Limit per Family Size: Enter the Current Maximum Move-in Income Limit for the household size.
Household income at move-in: For recertifications, only, enter the household income from the move-in certification.
Household size at move-in: For recertifications only, enter the household income from the move-in certification. On the adjacent
line, enter the number of household members from the move-in certification.

Household Meets Income Restriction at: Check the appropriate box for the income restriction that the household meets according
to what is required by the set-aside(s) for the project.

Current Income Limit x 140%: For recertifications only. Multiply the Current Maximum Move-in Income Limit by 140% and enter the
total. Below, indicate whether the household income exceeds that total. If the Gross Annual Income at recertification is greater
than 140% of the current income limit, then the available unit rule must be followed.

Part VI - Rent
Tenant Paid Rent: Enter the amount the tenant pays toward rent (not including rent assistance payments such as Section 8).
Rent Assistance: Enter the amount of rent assistance, if any.
Utility Allowance: Enter the utility allowance. If the owner pays all utilities, enter zero.
Other non-optional charges: Enter the amount of non-optional charges, such as mandatory garage rent, storage lockers, charges for
services provided by the development, etc.

Gross Rent for Unit: Enter the total of Tenant Paid Rent plus Utility Allowance and other non-optional charges.
Maximum Rent Limit for this unit: Enter the maximum allowable gross rent for the unit.
Unit Meets Rent Restriction at: Check the appropriate rent restriction that the unit meets according to what is required by the setaside(s) for the project.

Part VII - Student Status
If all household members are full time* students, check “yes”. If at least one household member is not a full time student,
check “no”.
If “yes” is checked, the appropriate exemption must be listed in the box to the right.
U.S. Department of Housing and Urban Development
Previous editions unusable

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HUD LIHTC Tenant Data Collection Form
Revised xxx 2010

HUD LIHTC Tenant Data Collection Form

OMB Approval No. xxxx-xxxx (Exp. x/xx/20xx)

*Full time is determined by the school the student attends.
Part VIII – Program Type
Mark the program(s) for which this household’s unit will be counted toward the property’s occupancy requirements. Under
each program marked, indicate the household’s income status as established by this certification/recertification. If the
property does not participate in the HOME, Tax-Exempt, Affordable Housing Disposition Program (AHDP) or other
housing program, leave those sections blank.
Tax Credit: Mark the appropriate box indicating the household’s designation. If the property does not have any occupancy
requirements in addition to those required by Section 42, mark the box that corresponds to the property’s minimum set aside. Upon
re-certification, if the household’s income exceeds 140% of the income limitation imposed by Section 42, mark “OI”.

HOME: If the property participates in the HOME program and the unit this household will occupy will count towards the HOME program
set asides, mark the appropriate box indicting the household’s designation.

Tax Exempt: If the property participates in the Tax Exempt Bond program, mark the appropriate box indicating the household’s
designation.

AHDP: If the property participates in the Affordable Housing Disposition Program (AHDP) program, and this household’s unit will count
towards the set aside requirements, select the appropriate box to indicate if the household is a VLI, LI or OI (at re-certification)
household.

Other: If the property participates in any other affordable housing program, complete the information as appropriate.
PUBLIC BURDEN STATEMENT
Public reporting burden for this collection of information is estimated to average 4 hours for each response. This includes the time for
collecting, reviewing, and reporting the data. The information will be used to measure the number of units of housing financed with the
Low-Income Housing Tax Credit (LIHTC) that are produced each year. The information will also be used to analyze the characteristics
of these housing units, and will be released to the public. This agency (HUD) may not collect this information, and you are not required
to complete this form unless it displays a currently valid OMB control number.

U.S. Department of Housing and Urban Development
Previous editions unusable

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HUD LIHTC Tenant Data Collection Form
Revised xxx 2010