HUD-52665 Family Portability Information - Housing Choice Voucher

Family Portability Information

U.S. Department of Housing
and Urban Development

Housing Choice Voucher Program

Office of Public and Indian Housing

OMB Approval No. 2577-0169
(exp. 04/30/2018)

Public reporting burden for this collection of information is estimated to average .50 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 of information unless that collection displays a valid OMB control number.
This collection of information is authorized under Section 8 of the U.S. Housing Act of 1937 (42 U.S.C. 1437f). The information is used to standardize the information
submitted to the receiving Public Housing Agency (PHA) by the initial PHA. In addition, the information is used for monthly billing by the receiving PHA.
Sensitive Information. The information collected on this form is considered sensitive and is protected by the Privacy Act. The Privacy Act requires that these records be
maintained with appropriate administrative, technical, and physical safeguards to ensure their security and confidentiality. In addition, these records should be protected
against any anticipated threats or hazards to their security or integrity which could result in substantial harm, embarrassment, inconvenience, or unfairness to any individual
on whom the information is maintained.
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 information is used for monthly billing by the receiving PHA. The SSN is used as a unique identifier. HUD may disclose this information to Federal, State and local
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: This portion of the form is to be completed by the initial PHA for a family that is moving out of the initial PHA’s jurisdiction under the portability procedures.

1. Head of Household Name

3. Voucher Number (if applicable)

2. Head of Household Social Security Number

4. Bedroom Size

5. Issuance Date
(mm/dd/yyyy)

6. Expiration Date
(mm/dd/yyyy)

7. Date of Last Income Examination
(mm/dd/yyyy)

8.

Annual income if new admission (not currently a voucher participant)

$ ___________________________

9.

Date by which initial billing must be received (90 days following the expiration date of the initial PHA voucher) (mm/dd/yyyy)

__________________________

10. Initial PHA administrative fee rate
$ ____________________________
(Note: include proration, if applicable. For example, if the proration factor for the year is 79% and your column B rate is $60, enter $47.4)
11. 80% of initial PHA ongoing administrative fee (line 10 x 0.8)

$ _____________________________

12. Receiving PHA to which family has been referred: ___________________________________________________.

Attachments:
a.

A copy of the voucher issued by the initial PHA.

b.

The most recent form HUD-50058 and copies of all related verification information for the current form HUD-50058. (Note: This is the latest
form HUD-50058 completed for either an applicant, a new admission, an annual reexamination, or an interim redetermination. It is not the form HUD50058 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 receiving PHA voucher that does not
expire before 30 days from the expiration date indicated in Item 6 (the expiration date on the initial PHA’s voucher) for the appropriate bedroom size (based
on the receiving PHA’s policies). I certify that the information contained on Part I of this form and the attached documents provided by my agency are 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.
Name of Certifying PHA Official __________________________________________
Signature

___________________________________________

Initial PHA Contact Name

___________________________________________

Phone Number

_________________

Type Full Name and Address of Initial PHA below

Email _______________________

Form Submission Date (mm/dd/yyyy) ____________________

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Part II-A Receiving PHA Information and Certification
Instructions: The receiving PHA must always complete Part II-A.
1. Head of Household Name

2. Head of Household Social Security Number

3. Voucher Bedroom Size (per receiving PHA’s policies)

4. HAP Contract Number (if applicable)

5. Receiving PHA administrative fee rate

$ ____________________________

(Note: include proration, if applicable. For example, if the proration factor for the year is 79% and your column B rate is $60, enter $47.4)

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.
Name of Certifying PHA Official _____________________________________________

Signature

_____________________________________________

Receiving PHA Contact Name

_____________________________________________

Phone Number

_________________

Type full Name and Address of Receiving PHA below

Email _______________________

Form Submission Date (mm/dd/yyyy) _____________________
Part II-B Family Status, Initial HAP Contract Execution and Billing Changes After HAP Contract Execution
Instructions: for initial billings, Part II-B must be completed by the receiving PHA and received by the initial PHA within 90 days following the expiration
date of the initial PHA’s voucher. For changes in the family status or the billing amount, Part II-B must be completed and sent within 10 working days from
the effective date of the change. 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 all statements below that apply:
1. The above family has failed to submit a request for tenancy approval for an eligible unit within the allotted time period. You may therefore
reissue your voucher to another family and, if applicable, modify any records concerning local preference usage and income targeting requirements.
STOP. 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. STOP. Do not complete remainder of form.

3. We executed a HAP contract on __________________ (mm/dd/yyyy) with an effective date of ________________ (mm/dd/yyyy) and are
billing your agency. The effective date of the family’s annual reexamination will be _________________ (mm/dd/yyyy). A copy of the new
form HUD-50058 is attached to this form. No other documentation is required. (Note: 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 HUD50058 for a portability move-in.) Complete line 10 below.

4. The HAP amount has changed effective ________________ (mm/dd/yyyy) for the family because of: (Check all applicable items. Complete
line 10 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 Yes
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No

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form HUD-52665 (08/2016)

5. The HAP payments have been abated effective _______________ (mm/dd/yyyy). Please suspend the HAP to owner portion from your payment
effective _______________ (mm/dd/yyyy) until further notice. STOP. Do not complete remainder of form.

6. The HAP payments that were abated beginning ________________ (mm/dd/yyyy) have resumed effective ________________ (mm/dd/yyyy).
Please resume payment of HAP effective ___________________ (mm/dd/yyyy). (Note: do not complete remainder of form unless line 4 above
also apply. In such cases, complete line 10 below.)

7. We will no longer bill your agency because we are terminating the family's participation in the program or the family is voluntarily leaving the
program.
Billing arrangement termination effective date:________________________ (mm/dd/yyyy).
Reason for termination: (specify)

STOP. Do not complete remainder of form.

8. We are absorbing the family into our program and terminating the billing arrangement effective: ____________________ (mm/dd/yyyy).
STOP. Do not complete remainder of form.

9. 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). (Note: submit this form again once
you know the outcome of the family’s search).

STOP. Do not complete remainder of form.

10. Billing Information
Regular Billing Amount:
a. Monthly HAP amount due
(line 12s or 12af of form HUD-50058)

_____________________

b. Ongoing admin fee
((1) lesser of: Part I, line 11 or Part II, line 5, or (2) amount otherwise agreed upon)

_____________________

$ 0.00
_____________________

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

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

_____________________

e. Hard-to-house fee, if applicable

____________________

f. Other (explain)

_____________________

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$ 0.00
____________________

g. Total additional amount (sum of lines d, e and f)
Total Billing Amount:

$ 0.00
h. Payment Due This Billing Submission (sum of lines c and g)
_____________________
(After this submission, billing amount is amount recorded on line c, unless otherwise notified by the receiving PHA.)
Comments:

Clear All

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