2528-0165 LIHTC Tenant Data Form

Proposed HUD LIHTC Tenant Data Collection Form

OMB Approval No. 2528-0165 (approval pending)

HUD LIHTC Tenant Data Collection Form
Certification Type:
If other, specify:

_____
(1=Initial Certification ; 2=Recertification; 3=Other) Effective Date of Certification:
_____________________________
LIHTC Qualification Date:

____________
____________
(YYYY-MM-DD)

Part I: Development Data
Compliance Agency Name: ______________________________
Property Name:
_______________
PIN:
_______________
Building Address: _______________
Unit Number:
_______________

BIN:
# Bedrooms:

_______________
_______________

Part II: Household Composition
Was Unit Vacant on December 31, 2015?  Yes;  No
HH
Mbr #

Last
Name

First
Name

Middle
Initial

Relationship to
Head of Household

(If Yes, no other tenant-specific information required.)
Race

Ethnicity

Disabled?

Date of Birth
(YYYY/MM/DD)

F/T student
(Y or N)

Last 4 Digits
of SSN

1
2
3
4
5
6
7

Part III: Gross Annual Income (Use ANNUAL Amounts)
Part III Removed in its Entirety

Part IV: Income from Assets
Part VI Removed in its Entirety
‘Effective Date at LIHTC Certification’ and ‘Household Size at Certification’ Moved to Part V

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

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HUD LIHTC Tenant Data Collection Form

Proposed HUD LIHTC Tenant Data Collection Form

OMB Approval No. 2528-0165 (approval pending)

Part V: Determination of Income Eligibility
Total Annual Income From All Sources:

$__________

Effective Date of LIHTC Income Certification:
Household Size at LIHTC Certification:
Household Meets LIHTC Income Restriction at:

__________
__________
 50% AMGI;

RECERTIFICATION ONLY:
Current Income Limit x 140%:
$______
Household Income Exceeds 140% at Recertification:

 60% AMGI;
If income restriction for this unit is set-aside
below elected ceiling, enter percentage. *

 Yes

 No

____%

*Do not enter the actual calculated percentage for tenant.

Current LIHTC Income Limit per Family Size:

Household Income at LIHTC Qualification Date: $______

$__________

Household Size at LIHTC Qualification Date:

______

Part VI: Monthly Rent
Tenant Paid Monthly Rent: $___________
Monthly Utility Allowance: $___________
Other Monthly Non-optional Charges: $___________
Maximum LIHTC Rent for this Unit:

Gross Monthly Rent for Unit: $___________
(Tenant Paid Rent plus Utility Allowance and Other Non-Optional Charges)

$___________

Unit Meets LIHTC Rent Restriction at:  50% AMGI;
 60% AMGI;
If rent for this unit is set-aside below
elected ceiling, enter percentage. *

Total Monthly Rent Assistance: $___________
Federal Rent Assistance: $___________
Other Rent Assistance: $___________
Source of Federal Rent Assistance:

______

1. HUD Multi-Family Project-Based Rental Assistance (PBRA)1
2. HUD Section 8 Moderate Rehabilitation
3. Public Housing Operating Subsidy
4. HOME Rental Assistance
1

_____%

*Do not enter the actual calculated percentage for tenant.

5. HUD Housing Choice Voucher (HCV), tenant-based
6. HUD Project-Based Voucher (PBV)
7. USDA Section 521 Rental Assistance Program
8. Other Federal Rental Assistance

Includes: Section 8 New Construction/Substantial Rehabilitation; Section 8 Loan Management; Section 8 Property Disposition; Section 202 Project
Rental Assistance Contracts (PRAC)

Part VII. Student Status
Are all Occupants Full-Time Students?  Yes

No

*Student Explanation:
1. TANF Assistance
2. Job Training Program
3. Single Parent/Dependent Child

If Yes, enter Student Explanation*: ______

4. Married/Joint Return
5. Previous Foster Care
6. Extended-Use Period

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. Next to each program marked, indicate the household’s income status as established by the certification/recertification.
 a. Tax Credit

 b. HOME

 c. Tax Exempt

 d. AHDP

 e. _____________
(Name of Program)

Income Status:
See Part V above.






 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

Proposed HUD LIHTC Tenant Data Collection Form

OMB Approval No. 2528-0165 (approval pending)

Privacy Act Information: This collection is authorized by 42 USC § 1437z–8. The collection of partial social
security numbers is permitted by 42 U.S.C. § 3543 and 3544. The information collected on these forms is
protected by the Privacy Act of 1974, Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d), and the Fair
Housing Act (42 U.S.C. 3601-19). This collection is mandatory, but disclosure by the tenant of race, ethnicity
and disability status is optional.
For information, assistance, or inquiry about the existence of records, contact the Privacy Act Officer at the
Department of Housing and Urban Development, 451 7th Street S.W., Washington, D.C. Written requests must
include the full name, Social Security Number, date of birth, current address, and telephone number of the
individual making the request.
Instructions
General Instructions: The purpose of this form is to enable reporting of federal low income housing tax credit data. The
definitions for all fields are to be understood in that context. All fields below must appear on the state TIC. A state may
not collect data in a field that differs from the applicable definition below. States are free to include other fields on their
TICs that are designed to collect other data. Displaying OMB information on the form, including the OMB form number, is
appropriate only if the HUD OMB-approved TIC remains unchanged. However, if any changes are made to the form
(changing words, adding signature blocks, etc) the OMB number, approval date, etc must not be included on the state
form. OMB rules do not allow for any modifications of an OMB form if the OMB number is used.
Part I - Development Data
Certification Type: Enter the type of tenant certification: Initial Certification (move-in), Recertification (annual recertification), or Other.
If Other, specify the purpose of the recertification (i.e., a unit transfer, a change in household composition, or other state-required
recertification).

Effective Date: Enter the effective date of the tax credit certification. If a self-certification was conducted after a verified income
certification, enter the self-certification date. Part IV below requests the date of the verified income certification.

LIHTC Qualification Date: Enter the most recent tax credit qualification date for the household that is less than or equal to the
certification effective date.

Compliance Agency Name: Enter the name of the agency which conducts income and rent compliance for this unit.
Property Name: Enter the name of the development.
PIN: Enter the Project Identification Number. Please include hyphens between the state abbreviation, allocating year, and projectspecific number. If there is not an established method of assigning PINs, HUD recommends using the following format: State Postal
Abbreviation - Allocation Year - First two digits of BIN (if those digits are project specific); e.g. CT-10-01.

BIN #: Enter the Building Identification Number (BIN) assigned to the building (from IRS Form 8609). According to IRS Notice 88-91,
the BIN consists of a two character state designation (identical to a postal state abbreviation) followed by a two digit designation
representing the year the credit is allocated, and a five digit numbering designation. For example, the identification number for one
of 25 buildings allocated a credit in 1987 by the Connecticut Housing Finance Authority (the only housing credit allocating agency in
the state) might read CT-87-00023.

Building Address: Enter the physical address of the building, including street number and name, city, state and zip code as provided
on the IRS 8609 Form.

Unit Number: Enter the unit number.
# Bedrooms: Enter the number of bedrooms in the unit.
Part II - Household Composition
Was Unit Vacant on December 31, 2015?: Check “Yes” if unit was vacant on December 31 of requesting year or check “No” if the
unit was occupied on this date. “1”=yes; “2”=no

Name: List first name, middle initial and last name of all occupants of the unit. For unborn child of pregnant household member, enter
“unborn”.

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
(including unborn child of pregnant household member); F – Foster child or Foster adult; L – Live-in caretaker; or N – None of the
above.

Race: Enter each household member’s race by using at least one of the following coded definitions: 1 – White; 2 – Black/African
American; 3 – American Indian/Alaska Native; 4 – Asian (4a – Asian India; 4b – Chinese; 4c – Filipino; 4d – Japanese; 4e – Korean; 4f –
U.S. Department of Housing and Urban Development
Previous editions unusable

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HUD LIHTC Tenant Data Collection Form

Proposed HUD LIHTC Tenant Data Collection Form

OMB Approval No. 2528-0165 (approval pending)

Vietnamese; 4g – Other Asian); 5 – Native Hawaiian/Other Pacific Islander (5a – Native Hawaiian; 5b – Guamanian or Chamorro; 5c –
Samoan; 5d – Other Pacific Islander); 6 – Other; or 8 – tenant did not respond.

Ethnicity: Enter each household member’s ethnicity by using one of the following coded definitions: 1 – Hispanic or Latino; 2 – not
Hispanic or Latino; or 3 – Tenant did not respond.

Disabled?: Check yes (“1” =yes; “2”=no; or “3”=Tenant did not respond) 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.”
Date of Birth: Enter each household member’s date of birth.
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. “1”
=yes; “2”=no

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. If tenant does not have a SSN or alien registration number, enter
“0000”.

Part III - Annual Income
Part III Removed in its Entirety.
Part IV - Income from Assets
Part VI Removed in its Entirety
‘Effective Date at LIHTC Certification’ and ‘Household Size at Certification’ Moved to Part V
Part V – Determination of Income Eligibility
Total Annual Household Income From all Sources: Refer to HUD Handbook 4350.3 for calculation of annual income and income
from assets.

Effective Date of LIHTC Income Certification: If the current Tenant Income Certification (TIC) did not update the tenant’s income
information and the TIC is reporting previous income, enter the effective date of the income qualification corresponding to the total
annual household income. If income certification is not required annually, this may be different from the effective date listed in Part I.

Household Size at LIHTC Certification: If the current Tenant Income Certification (TIC) did not update the tenant’s household size
information and the TIC is reporting previous information, enter the number of tenants corresponding to the total annual household
income entered in Box L. If income certification is not required annually, this may be different from the number of tenants listed in
Part II.

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

If the income restriction for this unit is set-aside below elected ceiling, enter the percent required. If this unit has an incomerestriction set below the elected federal maximum, enter the percent required.

Current LIHTC Income Limit per Family Size: Enter the Current Maximum Move-in Income Limit for the household size. The
income limit must be the IRS Section 42 income limit associated with the federal tax credit set-aside.

For Recertifications Only:
Current Income Limit x 140%: For recertifications only, multiply the Current Maximum Move-in Income Limit by 140% and enter
the total.

Household Income Exceeds 140% at Recertification: Indicate whether the household income exceeds 140% of the current
income limit.

Household Income at LIHTC Qualification Date: For recertifications, only, enter the household income at the time of LIHTC
qualification.
U.S. Department of Housing and Urban Development
Previous editions unusable

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HUD LIHTC Tenant Data Collection Form

Proposed HUD LIHTC Tenant Data Collection Form

OMB Approval No. 2528-0165 (approval pending)

Household Size at LIHTC Qualification Date: For recertifications only, enter the household income at the time of LIHTC
qualification. On the adjacent line, enter the number of household members at the time of program qualification.

Part VI - Monthly Rent
Tenant Paid Monthly Rent: Enter the amount the tenant pays toward rent (not including rent assistance payments such as Section
8).

Monthly Utility Allowance: Enter the utility allowance. If the owner pays all utilities, enter zero.
Other Monthly 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 Monthly Rent for Unit: Enter the total of Tenant Paid Rent plus Utility Allowance and other non-optional charges. The total
may NOT include amounts other than Tenant Paid Rent, Utility Allowance and other non-optional charges. In accordance with the
definition of Gross Rent in IRC §42(g)(2)(B), it may not include any rent assistance amount.
Total Monthly Rent Assistance: Enter the amount of total rent assistance received, if any.
Federal Rent Assistance: Enter the amount of rent assistance received from a federal program, if any.
Other Rent Assistance: Enter the amount of non-federal rent assistance received, if any.
Source of Federal Rent Assistance: If federal rent assistance is received, indicate the program source

Maximum LIHTC Rent Limit for this Unit: Enter the maximum allowable gross rent for the unit. This amount must be the maximum
amount allowed by the Current Income Limit per Family Size—specifically, the max rent limit for the federal 50% or 60% set aside.

Unit Meets LIHTC Rent Restriction at: Indicate the appropriate rent restriction that the unit meets according to what is required by
the set-aside(s) for the project. If your agency requires a rent restriction lower than the federal limit, enter the percent required.

If rent for this unit is set-aside below elected ceiling, enter the percent required. If this unit has a rent level set below the
elected federal maximum, enter the percent required.

Part VII - Student Status
Are all Occupants Full-Time Students?: If all household members are full-time students, check “yes”. Full-time status is
determined by the school the student attends. If at least one household member is not a full-time student, check “no”.
(“1” =yes; “2”=no)
Student Explanation: If all occupants are full-time students, indicate the appropriate exemption as listed in the box to the
right. Note that not all exemptions listed are applicable to each state, e.g. Extended-Use Period.
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 the 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 40 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