Housing Choice Voucher (HCV), Program and Tribal HUD-VASH

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Request for Tenancy Approval
Housing Choice Voucher Program 
The public reporting burden for this information collection is estimated to be 30 minutes, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The Department of Housing and Urban Development (HUD) is authorized to collect the information on this form by Section 8 of the U.S. Housing Act (42 U.S.C. 1437f). Form is only valid if it includes an OMB Control Number.
HUD is committed to protecting the privacy of individuals’ information stored electronically or in paper form, in accordance with federal privacy laws, guidance, and best practices. HUD expects its third-party business partners, including Public Housing Authorities, who collect, use maintain, or disseminate HUD information to protect the privacy of that information in
Accordance with applicable law.
When the participant selects a unit, the owner of the unit completes this form to provide the PHA with information about the unit. The information is used to determine if the unit is eligible for rental assistance. HUD will not disclose this information except when required by law for civil, criminal, or regulatory investigations and prosecutions. 
    1. Name of Public Housing Agency (PHA)
    2. Address of Unit (street address, unit #, city, state, zip code)
    3. Requested Lease Start Date
    4. Number of Bedrooms
    5. Year Constructed
    6. Proposed Rent
    7. Security Deposit Amt
    8. Date Unit Available for Inspection
    9. Structure Type
    10. If this unit is subsidized, indicate type of subsidy:
    • Single Family Detached (one family under one roof)
    • Semi-Detached (duplex, attached on one side)
    • Rowhouse/Townhouse (attached on two sides)
    • Low-rise apartment building (4 stories or fewer)
    • High-rise apartment building (5+ stories)
    • Manufactured Home (mobile home)
    • Section 202
    • Section 221(d)(3)(BMIR)
      
    • Tax Credit
    • HOME
      
    • Section 236 (insured or uninsured)
      
    • Section 515 Rural Development
      
    • Other (Describe Other Subsidy, including any state or local subsidy) ___________________________
    11.  Utilities and Appliances
The owner shall provide or pay for the utilities/appliances indicated below by an “O”. The tenant shall provide or pay for the utilities/appliances indicated below by a “T”. Unless otherwise specified below, the owner shall pay for all utilities and provide the refrigerator and range/microwave.
Item
Specify fuel type
Paid by
Heating
    • Natural gas
    • Bottle gas
    • Electric
    • Heat Pump
    • Oil
    • Other

Cooking
    • Natural gas
    • Bottle gas
    • Electric


    • Other

Water Heating
    • Natural gas
    • Bottle gas
    • Electric

    • Oil
    • Other

Other Electric






Water






Sewer






Trash Collection






Air Conditioning






Other (specify)












Provided by
Refrigerator






Range/Microwave






						
12. Owner’s Certifications
    a. The program regulation requires the PHA to certify that the rent charged to the housing choice voucher tenant is not more than the rent charged for other unassisted comparable units. Owners of projects with more than 4 units must complete the following section for most recently leased comparable unassisted units within the premises.
    c. Check one of the following:
    • Lead-based paint disclosure requirements do not apply because this property was built on or after January 1, 1978.
    • The unit, common areas servicing the unit, and exterior painted surfaces associated with such unit or common areas have been found to be lead-based paint free by a lead-based paint inspector certified under the Federal certification program or under a federally accredited State certification program.
    • A completed statement is attached containing disclosure of known information on lead-based paint and/or lead-based paint hazards in the unit, common areas or exterior painted surfaces, including a statement that the owner has provided the lead hazard information pamphlet to the family.
13. The PHA has not screened the family’s behavior or suitability for tenancy. Such screening is the owner’s responsibility.
14. The owner’s lease must include word-for-word all provisions of the HUD tenancy addendum.
15. The PHA will arrange for inspection of the unit and will notify the owner and family if the unit is not approved.
Address and unit number
Date Rented
Rental Amount
       
    1. 



    2. 



    3. 



    b. The owner (including a principal or other interested party) is not the parent, child, grandparent, grandchild, sister or brother of any member of the family, unless the PHA has determined (and has notified the owner and the family of such determination) that approving leasing of the unit, notwithstanding such relationship, would provide reasonable accommodation for a family member who is a person with disabilities.







Print or Type Name of Owner/Owner Representative
Print or Type Name of Household Head
Owner/Owner Representative Signature
Head of Household Signature
Business Address
Present Address
Telephone Number
Date (mm/dd/yyyy)
Telephone Number
Date (mm/dd/yyyy)