HUD 52665 Family Portability Information

Family Portability Information
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U.S. Department of Housing
and Urban Development
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Privacy Act Statement. The Department of Housing and Urban Development (HUD) is authorized to collect the information required on this form by Section 8 of the U.S.
Housing Act of 1937 (42 U.S.C. 1437f) and by the Housing and Community Development Act of 1987 (42 U.S.C. 3534(a)). Collection of this information, including SSN and
annual income, is mandatory. The information is used to standardize the information submitted to the receiving Public Housing Agency (PHA) by the initial PHA. In addition,
the i nformation is used f or m onthly b illing by th e r eceiving P HA. T he S SN is used a s a u nique i dentifier. HUD m ay d isclose t his information t o Federal, S tate a nd l ocal
agencies when relevant to civil, criminal, or regulatory investigations and prosecutions. It will not be otherwise disclosed or released outside of HUD, except as permitted or
required by law. Failure to provide any of the information may result in delay or rejection of a family port.

Part I Initial PHA Information and Certification
Instructions: 7KLVSRUWLRQRIWKHIRUPLVWREHFRPSOHWHGE\WKH initial PHA IRUDIDPLO\WKDWLVPRYLQJRXWRIWKH initial PHA’s MXULVGLFWLRQXQGHUWKHSRUWDELOLW\SURFHGXUHV
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Attachments:
a. A copy of the voucher issued by the initial PHA.
b. A copy of the current form HUD-50058 and copies of the income verification for the current form HUD-50058. (Note: This is the
latest form H UD-50058 completed for either an admission, an a nnual reexamination, or an interim redetermination. I t is not the form
HUD-50058 that the initial PHA completes to report the portability move-out.)
Certification Statement:
The family
is a current program participant or
is not a current program participant but is income-eligible in the receiving PHA’s
jurisdiction (see line 8 above), and the voucher was issued in accordance with the program regulations. Please issue the family a r eceiving
PHA voucher that does not expire before the expiration date indicated in Item 6 (the expiration date on the initial PHA’s voucher) for the
appropriate b edroom size ( based o n the r eceiving P HA’s p olicies). I cer tify that the information co ntained o n P art I of t his form a nd t he
attached documents provided by my agency is true and correct. My agency will promptly reimburse amounts paid on behalf of the above
family within 30 calendar days of receipt of Part II of this form and thereafter ensure that subsequent billing payments are received by your
agency no later than the fifth working day of each month. Failure to comply with these payment due dates may result in the transfer of the
family's voucher in accordance with program rules and regulations.
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IRUPHUD-526659/2014
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Part II-A Receiving PHA Information and Certification
Instructions: 7KH receiving PHA PXVWDOZD\VFRPSOHWH3DUW,,$
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Certification Statement:
I certify that the information contained on Part II of this form and, if applicable, the attached form HUD-50058 is true and correct and that
my agency will promptly remit any overpayment to your agency.
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Part II-B Family Status, Initial HAP Contract Execution and Billing Changes After HAP Contract Execution
Instructions: 3DUW,,%PXVWEHFRPSOHWHGDQGPDLOHGE\WKH receiving PHA ZLWKLQZRUNLQJGD\VIURPWKHGDWHD+$3FRQWUDFWLVH[HFXWHGRQEHKDOIRI WKH
IDPLO\ RU IURPW KH HIIHFWLYH GDWHRI W KHF KDQJHL QW KHI DPLO\V WDWXV RU ELOOLQJ DPRXQW The receiving PHA does not submit the billing form each month
unless the monthly amount due changes or both PHAs agree to a different billing schedule that requires a more frequent billing submittal.

Check each statement below that applies:
1. The above family has failed to submit a request for lease a pproval for an eligible unit within t he allotted time p eriod. You may
therefore reissue your voucher to another f amily an d, if applicable, modify any records concerning local preference usage and
income targeting requirements. Do not complete remainder of form.
2. We have executed a HAP contract on behalf of the family and are absorbing the family into our own program effective
_____________(mm/dd/yyyy). You may reissue your voucher to another family. Do not complete remainder of form.
3. We executed a HAP contract effective __________________ (mm/dd/yyyy) on behalf of the family and are billing your agency.
A copy of the new form HUD-50058 is attached to this form. No other documentation is required. (Receiving PHAs are
required to complete and submit a form HUD-50058 for families moving into their jurisdiction under portability. The
receiving PHA may elect to conduct a special recertification of the family to conform the dates of the unit inspection and
recertification, but is not required to do so by HUD in order to complete the form HUD-50058 for a portability move-in.)
Go to line 9 below.
4. The HAP amount has changed effective ________________ (mm/dd/yyyy) for the family because of: (Check all applicable items.
A current copy of the form HUD-50058 must be attached to this form. No other documentation is required.) Go to line 9
below.
____ annual recertification
____ interim/special recertification
____ change in payment standard
____ the family moved to another unit in the receiving PHA jurisdiction.
____ other:(specify)

Comments continued on separate page
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No
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IRUPHUD-526659/2014
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5. The HAP payments: (Check one)
____ have been abated effective _______________ (mm/dd/yyyy).
Please suspend the HAP to owner portion from your payment effective _______________ (mm/dd/yyyy) until further notice.
____ that were abated beginning ________________ (mm/dd/yyyy) have been resumed
effective ________________ (mm/dd/yyyy).

6. We will no lo nger b e b illing your agency b ecause we a re t erminating t he family's p articipation in the p rogram o r t he family is
voluntarily leaving the program.
Billing arangement termination effective date:________________________ (mm/dd/yyyy)
Reason for termination:(specify)
7. We are absorbing the family into our program and terminating the billing arrangement effective: ____________________.
(mm/dd/yyyy)
8. The HAP contract has been terminated effective ___________________ (mm/dd/yyyy) and no new HAP contract has yet been
executed on behalf of the family.
The family:
____ will not be remaining in our jurisdiction and has been referred to your agency.
____ intends to remain in our jurisdiction. The family’s voucher expires _________________ (mm/dd/yyyy).
9. Billing Information
Regular Billing Amount
a. Monthly HAP amount due
(line 12s or 12af of form HUD-50058)

___________________

b. Ongoing admin fee (80% of initial PHA fee or

____________________

amount otherwise agreed upon) (line 10 of Part I of this form)

c. Total regular monthly billing amount
(sum of lines a and b)

$0.00
____________________

Additional Amount Due, If Applicable
d. Prorated HAP to owner from ____________to _____________

____________________

e. Hard-to-house fee

____________________

f. Other (explain)

____________________

$0.00
g. Total additional amount (sum of lines d, e and f)
____________________

Billing Amount

h. Payment Due This Billing Submission (sum of lines c and g.)

$0.00
_______________

(After this submission, billing amount is amount recorded on line c, unless otherwise notified by the receiving PHA.)

This form may be reproduced on local office copiers

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form HUD-52665 (09/2014)
ref. Handbook 7420.8