HUD-52860 - Origin Inventory Removal Application

Inventory Removals Application
HUD-52860

U.S. Department of Housing
and Urban Development
Office of Public and Indian Housing

OMB Approval No. 2577-0075
(exp. 01/31/2021)

The information collection requirements contained in this document have been approved by the Office of Management and Budget (OMB)
under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3520) and assigned OMB control number 2577-0075. There is no personal
information contained in this application. Information on activities and expenditures of grant funds is public information and is generally
available for disclosure. Recipients are responsible for ensuring confidentiality when disclosure is not required. In accordance with the
Paperwork Reduction Act, HUD may not conduct or sponsor, and a person is not required to respond to, a collection of information unless
the collection displays a currently valid OMB control number.
This general information is required to request HUD approval to remove public housing property (residential or non-residential) from public
housing requirements, including use restrictions imposed under the Annual Contributions Contract (ACC) and the Declaration of Trust
(DOT)/Declaration of Restrictive Covenants (DoRC). PHAs may request such HUD approval under the following laws: demolition and
disposition (Section 18 of the 1937 Act and 24 CFR part 970); voluntary conversion (Section 22 of the 1937 Act and 24 CFR part 972);
required conversion (Section 33 of the 1937 Act and 24 CFR part 972); homeownership (Section 33 of the 1937 Act and 24 CFR part 906);
retentions under 2 CFR 200.311 (PIH Notice 2016-20 or subsequent notice); and eminent domain (PIH Notice 2012-8, or subsequent
notice).
Note: This form requests general information only and PHAs are required to submit an additional addendum for the specific type of
proposed removal. This form in addition to the applicable addendum are collectively known as the SAC application since these applications
are processed by HUD’s Special Applications Center (SAC). HUD will use this information to review PHA requests, as well as to track
removals for other record keeping requirements. Responses to this collection of information are statutory and regulatory to obtain a benefit.
The information requested does not lend itself to confidentiality. PHAs are required to submit this information electronically to HUD
through the Inventory Removals Submodule of the Inventory Management System/PIH Information Center (IMS/PIC) system (or a later
electronic system prescribed by HUD). IMS/PIC will assign each SAC application a “DDA” number.
This form does not apply to proposed removals (conversions) under HUD’s Rental Assistance Demonstration (RAD) program; and the
instructions for RAD application submissions via IMS/PIC is provided and governed by a separate OMB-approved HUD form.

Section 1: General Information
1. Date of Application:
2. Name of Public Housing Agency (PHA):
3. PHA Identification Number:
4. PHA Address:
5. Contact Person Name at PHA:
6. Contact Person Phone No.:
7. Contact Person Email:
8. Is the PHA operating under any remedial order, compliance agreement, final judgment,
consent decree, settlement agreement or other court order or agreement, including but not
limited to those related to a fair housing or other civil rights finding of noncompliance?
If yes, attach a narrative description of explaining how the proposed removal is consistent with
such order, agreement or other document

Yes
No

Section 2: N/A
Section 3: PHA Plan, Board Resolution, Environmental Review and Local Government Consultation
1. PHA Plan:
Year of PHA Plan that includes the removal action and approval
Year:
Approval Date:
date:
Attach evidence that the removal action is included in the approved PHA Plan and approval date
2. Board Resolution that approves the removal action; and PHA’s submission of removal application to HUD:
Board Resolution Number:
Board Resolution Date:
Attach a copy of signed PHA Board Resolution

Provide attachments as needed. All attachments
must reference the Section and line number to which they apply
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HUD under 24 CFR part 50
Responsible Entity (RE) under 24 CFR part 58
Name of RE:
Date ER was conducted:
Attach a copy of HUD’s approval of the Environmental Review (i.e. HUD-7015.16). See instructions.
4. Local Government Consultation:
The PHA covers the following
jurisdiction(s):
5. Date(s) of letter(s) of support from (local) government officials:
Attach copies of all letters of support from local government officials, along with a narrative description of the PHA’s
consultation (if applicable)
3. Environmental Review:
Check the box for the entity that conducted
the Environmental Review (ER):

Section 4: Description of Existing Development
1.
2.
3.
4.
5.
6.
7.
8.
9.

Name of Development:
Development Number:
Date of Full Availability (DOFA):
Number of Residential Buildings:
Number of Non-Residential Buildings:
Date Constructed:
Is the Development Scattered Site?
Yes
No
Number of Buildings (single family, duplexes, 3-plexes, 4-plexes, other):
Number of Types of Structures (row houses, walk-up units, high-rise
unit):
10. Total Acres in Development:
Total Units Being Used
11. Existing Unit
General
Elderly/Disabled
Total Units in
for Non-Dwelling
Distribution
Occupancy
Designated Units
Development
Purposes
0 – Bedroom
1 – Bedroom
2 – Bedrooms
3 – Bedrooms
4 - + Bedrooms
Total
Attach a description of the distribution of UFAS accessible units (bedroom size; unit type, e.g., mobility or sensory)
Section 5: Description of Proposed Removal
1. Type of Removal Action(s)
(e.g., Demolition, Disposition, Disposition to allow for Public Housing Mixed-Finance
Modernization, Demolition and Disposition, DeMinimis Exception under Demolition,
Voluntary Conversion, Required Conversion, Homeownership, Eminent Domain,
Retention under 2 CFR part 200)
2. Proposed Action by Unit Type (e.g. bedroom size)
UFAS
UFAS
Total Units Being
Existing Unit
General
Elderly/Disabled
Mobility Sensory
Used for NonDistribution
Occupancy
Designated Units
Units
Units
Dwelling Purposes
0 – Bedroom
1 – Bedroom
2 – Bedrooms
3 – Bedrooms
4 - + Bedrooms
Total
Provide attachments as needed. All attachments
must reference the Section and line number to which they apply
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Total Units in
Development

form HUD-52860 (04/2018)

3. Proposed Action by Building Type
Buildings to be Demolished Only
Buildings to be Disposed of Only
Residential Buildings
Non-Residential Buildings
Total Buildings
If the removal action is for only a portion of property at a contiguous site, attach a site map
4. Total Acreage Proposed for Removal (if applicable)
(a) Attach a description of the land (e.g. survey, copy of the legal description)
(b) Attach a copy of the recorded Declaration of Trust (DOT)/Deed of Restrictive Covenant (DoRC)
(c) If the removal action is for only a portion of property at a contiguous site, attach a site map.
$
5. Estimated Value of the Proposed Property
Yes
No
(a) Was an independent appraisal conducted to determine the estimated Fair Market Value?
(b) If yes, date of appraisal and
Date:
Name:
name of appraiser:
(c) If not, describe other form of
valuation used:
Attach an executive summary of the appraisal or other form of valuation
6. Timetable
Estimated Number of Days
Activity
After HUD Approval:
(a)Begin Relocation of Residents:
N/A
-if vacant or for non-dwelling building
(b)Complete Relocation of Residents: N/A
-if vacant or for non-dwelling building
(c) Execute Contract for Removal
(d) Removal of the property
Section 6: Relocation
1. Number of Units Proposed for Removal that are Occupied as of the Submission Date of this
SAC application:
(Note: These numbers are not editable and automatically populated when application is submitted)

2. Number of individual residents that the PHA estimates will be displaced by this removal
action:
Attach a summary of the number of individual residents estimated to be displaced by race and national origin and a
summary of households estimated by be displaced by who have a member who is a person with a disability
PHA staff
3. Who will provide relocation counseling and advisory services to
Another Entity contracted by the PHA Describe:
residents?
Attach a description of the relocation counseling and advisory services that the will be provided to residents who will be
displaced by this action
4. What is the estimated costs of relocation and moving expenses
$
(including advisory services)?
Capital Funds
Operating Funds
5. What is the anticipated source of funds for relocation
Funding Source Year:
and moving expenses (including advisory services)?
Non-1937 Act Funds (describe:
)
Public Housing. If checked, number:
Section 8 HCV (existing resources. If checked, number:
6. What comparable housing
Section 8 HCV (new award of TPVs) (see question #7).
resources does the PHA
expect to offer to
If checked, number:
displaced residents?
PBV Unit. If checked, number:
Other (attach description). If checked, number:
Attach a summary of the comparable housing resources that the PHA expects to offer to be displaced residents.

Provide attachments as needed. All attachments
must reference the Section and line number to which they apply
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Yes - Replacement TPVs.
If checked, number:
Yes - Relocation TPVs.
If checked, number:
No TPVs will be requested
Attach a brief explanation supporting the TPV request. See PIH Notice 2017-10 and PIH Notice 2018-04 (or any successor
notices). If the PHA is a public housing only-PHA, the PHA must partner with a PHA that administers an HCV program.
7. Tenant Protection Vouchers (TPVs):
If the PHA is eligible to receive TPVs in connection
with the proposed removal action, how many TPVs is
the PHA requesting?

Section 7: Resident Consultation
1. Will any residents be displaced or otherwise affected by the
Yes
No
proposed removal action? If yes, date(s) PHA consulted with
Date(s):
residents?
Attach a narrative description of consultation process, along with supporting documentation (e.g., agenda, meeting
notices; sign-in sheets; meeting minutes, print-out of written or email consultation)
Yes
No
2. Is there a Resident Council (at affected development)?
Name:
Date(s):
If yes, name of Resident Council and dates PHA consulted it:
N/A to removal action
Attach a narrative description of consultation process, along with supporting documentation e.g. meeting notices; sign-in
sheets; meeting minutes, print-out of written or email consultation)
Yes
No
3. Is there a Resident Council (PHA-wide jurisdiction)?
Name:
Date(s):
If yes, name of Resident Council and dates PHA consulted it:
N/A to removal action
Attach a narrative description of consultation process, along with supporting documentation e.g. meeting notices; sign-in
sheets; meeting minutes, print-out of written or email consultation)
Name of RAB:
4. Date(s) PHA consulted with the Resident Advisory Board (RAB)
Date(s):
(as defined in 24 CFR 903.13)
N/A to removal action
Attach a narrative description of consultation process, along with supporting documentation e.g. meeting notices; sign-in
sheets; meeting minutes, print-out of written or email consultation)
5. Did the PHA receive any written comments from residents or
Yes
No
resident groups/organizations during the consultation process?
If yes, attach comments received, along with an evaluation by the PHA
Section 8: N/A
Section 9: PHA Certification of Compliance
Acting on behalf of the Board of Commissioners of the PHA, as its Chairman, Executive Director, or other authorized
PHA official, I approve the submission of this SAC Application known as DDA #
for removing public
housing property from public housing use restriction, of which this document is a part, and make the following
certifications, agreements with, and assurances to the Department of Housing and Urban Development (HUD) in
connection with the submission of this SAC application and the implementation thereof:
1. All information contained in this SAC application (including all supporting documentation, attachments and required form
HUD-52860 addendums) is true and correct as of today’s date.
2. Resident demographic data in the IMS/PIC system is updated and current as of the date of the submission of this SAC
application.
3. The PHA will comply with all applicable fair housing and other civil rights requirements, including but not limited to HUD’s
general non-discrimination and equal opportunity requirements listed at 24 CFR 5.105(a), as well as the duty to affirmatively
further fair housing (AFFH) related to this SAC application. AFFH includes ensuring that the proposed inventory removal
development is not in conflict with fair housing goals and strategies in my agency’s PHA or MTW Plan, and is consistent
with my agency’s obligation to AFFH, certification and supporting activities. The PHA conducted the submission
requirements of this SAC application (including removal justification; resident consultation, etc.) in conformity with Title
Provide attachments as needed. All attachments
must reference the Section and line number to which they apply
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VI of the Civil Rights Act of 1964, the Fair Housing Act, Section 504 of the Rehabilitation Act of 1973, title II of the
Americans with Disabilities Act of 1990, state or local accessibility requirements, and other applicable civil rights laws. If
HUD approves this SAC application, the PHA will carry out and implement this removal action (including relocation, if
applicable), in conformity with all applicable civil rights requirements. The requirements for AFFH can be found at 24
CFR §§ 5.150-5.152, 5.154, 5.156, 5.158, 5.160, 5.162, 5.164, 5.166, 5.168, and 5.169-5.180.
4. The removal action proposed in this SAC application does not violate any remedial civil rights order or agreements,
conciliation agreements, voluntary compliance agreements, final judgments, consent decrees, settlement agreements or other
court orders or agreements to which the PHA is a party. If the PHA is operating under such a document, it must indicate this
by uploading a document to the SAC application that provides a citation to the document and explains how the proposed
demolition or disposition is consistent with such document.
5. If the PHA is a non-qualified PHA under the Housing and Economic Recovery Act of 2008 (HERA), it has complied with
the PHA Plan requirements regarding the proposed removal action at 24 CFR part 903 and the applicable statutory removal
authority. For instance, if the removal action is a demolition or disposition, the PHA must describe the demolition or
disposition in its PHA Plan or in a Significant Amendment to that PHA Plan and that description must be substantially
identical to the description in the SAC application. If the PHA is a qualified PHA, the PHA certifies that it has discussed the
removal action at a public hearing.
6. The PHA has conducted all applicable resident consultation and will conduct all relocation activities associated with this
SAC application in a manner that is effective for persons with hearing, visual, and other communication-related disabilities
consistent with Section 504 of the Rehabilitation Act of 1973 (24 CFR 8.6) and with 49 CFR 24.5, and as applicable, the
Americans with Disabilities Act of 1990. The PHA will take reasonable steps to ensure meaningful access to their programs
and activities for persons who have limited ability to read, speak, or understand English – i.e., individuals who have limited
English proficiency (LEP).
7. The PHA will comply with all applicable Federal statutory and regulatory requirements and other HUD requirements,
including applicable PIH Notices, in carrying out the implementation this SAC application, as approved by HUD. The PHA
specifically certifies that the property proposed for removal in this SAC application is in compliance with Declaration of
Trust (DOT) or Declaration of Restrictive Covenants (DoRC) requirements.
8. The PHA will comply with the terms and conditions of any HUD approval that HUD may issue for this SAC application,
including requirements applicable to future use, record-keeping and reporting; and will specifically retain records of the SAC
application and its implementing actions of HUD’s approval of this SAC application for a period of not less than 3 years
following the last required action of HUD’s approval. The PHA further certifies that it will make such records available for
inspection by HUD, the General Accountability Office and the HUD Office of Inspector General. If the PHA wants to make
any material changes from what it described in its SAC application and/or HUD’s approval of the SAC application, it will
request HUD approval for such changes, in accordance with applicable HUD guidance.
9. The PHA will not take any action to remove or otherwise operate the property proposed for removal outside of public housing
requirements until it receives written approval of this SAC application from HUD.
10. If any units proposed for removal by this SAC application are subject to an Energy Performance Contracting (EPC), the PHA
agrees to comply with additional instructions provided by HUD regarding the EPC and will not take any steps to implement
this SAC application (if approved by HUD), without receiving confirmation from HUD that all applicable EPC requirements
are satisfied.
11. If any units proposed for removal by this SAC application are subject to a Capital Fund Financing Plan (CFFP) or other
Section 30 debt, the PHA agrees to comply with additional instructions provided by HUD regarding the CFFP or other
Section 30 and will not take any steps to implement this application (if approved by HUD), without receiving confirmation
from HUD that all applicable CFFP or other Section 30 requirements are satisfied.
12. If the PHA is in the process of removing all of its public housing units from its ACC low-rent inventory through this or other
SAC applications and/or other pending removal actions, including the Rental Assistance Demonstration (RAD) program, the
PHA agrees to comply with additional instructions provided by HUD regarding the close-out of its public housing portfolio.

I hereby certify that all the information stated herein, as well as any information provided in the accompaniment
herewith, is true and accurate.
Warning: HUD will prosecute false claims and statements. Conviction may result in criminal and/or civil penalties. (18 U.S.C.
1001, 1010, 1012; 31 U.S.C. 3729, 3802)

Name of Authorized Official
Official Title:
Signature:
Date:
Form HUD-52860 Instructions
Provide attachments as needed. All attachments
must reference the Section and line number to which they apply
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Refer to SAC website at www.hud.gov/sac for more information
This form request general information from PHAs about proposed removal actions under the following laws: demolition and disposition
(Section 18 of the 1937 Act and 24 CFR part 970); voluntary conversion (Section 22 of the 1937 Act and 24 CFR part 972); required
conversion (Section 33 of the 1937 Act and 24 CFR part 972); homeownership (Section 32 of the 1937 Act and 24 CFR part 906);
retentions (PIH Notice 2016-20 and 2 CFR 200.311); and eminent domain (PIH Notice 2012-8, or replacement notice). This form is
the first part of a SAC application that must be submitted via the fields in the Inventory Removal Submodule of IMS/PIC (or replacement
system).
PHAs must complete the sections of this form where there is no field in the IMS/PIC SAC application for the requested information.
PHAs must then upload this form and other supporting documentation requested by this form to the IMS/PIC SAC application. PHAs
must label that supporting documentation by section number of this form and/or by name (e.g. Resident Consultation). PHAs must
complete and submit applicable addendums as indicated below as part of a SAC application. PHAs must refer to the applicable
regulations, PIH notices and other program guidance noted above for detailed requirements on the submissions required for the specific
removal action proposed in the SAC application at SAC web site.
Proposed Removal Action
Section 18 Disposition and/or Demolition
Section 18 Demolition Rehab Needs and Cost-Test
Section 32 Homeownership
Section 33 Required Conversion
Section 22 Voluntary Conversion
Eminent Domain
Part 200 Retention

Additional HUD Form Required
HUD-52860-A
HUD-52860-B
HUD-52860-C
HUD-52860-D
HUD-52860-E
HUD-52860-F
HUD-52860-G

NOTE: The removal of public housing units from the PHA’s inventory through these actions will impact (decrease) the PHA’s
Operating and Capital Fund subsidy from HUD. See 24 CFR 990.190 and PIH Notice 2017-22 (or successor notice) for impacts on
Operating Fund. Capital Funds for units will terminate at the time the units are removed from ACC via IMS/PIC. However, PHAs
may be eligible for Demolition Disposition Transition Funding (DDTF) pursuant to 24 CFR 905.400(j).
Section 1: General Information
Some fields will automatically populate from IMS/PIC. If not, complete all fields.
Section 2: N/A
Section 3: PHA Plan, PHA Board Resolution, Environmental Review and Local Government Consultation
Refer to the regulation, PIH Notice or other HUD guidance document for guidance on these requirements for the specific removal action
proposed, but generally the following apply:
PHA Plan: PHAs must include the removal action in their approved PHA plan for all SAC applications.
Board Resolution: PHAs must obtain a board resolution approving the removal action for all SAC applications. For demolitions and
dispositions proposed under 24 CFR part 970, the board resolution must be dated after the date of resident and local government
consultation.
Environmental Clearance: HUD will not process or approve a SAC application without evidence that the proposed removal action has
received Environmental Clearance. This evidence will generally be a copy of a HUD signed Authority to Use Grant Funds (HUD7015.16 form or subsequent form) for the proposed removal action (including future use, if known) to evidence an environmental review
acceptable to HUD was completed under 24 CFR part 58. In some instances, evidence of Environmental Clearance may be a letter
from the Responsibly Entity stating the activity was exempt or categorically excluded under 24 CFR part 58. The only exception to
obtaining Environmental Clearance under 24 CFR part 58 is if HUD, in its sole discretion, decides to complete the environmental
review itself under 24 CFR part 50. In this case, the applicable local HUD Office of Public Housing must have actually completed the
environmental review and determined the action has Environmental Clearance before HUD will process or approve a SAC application.
Local Government Consultation: PHAs must consult with their local government officials and obtain a letter of support for all SAC
applications (except for eminent domain and homeownership). For demolitions and dispositions proposed under 24 CFR part 970,
PHAs must include a narrative description of its consultation with local government officials.

Provide attachments as needed. All attachments
must reference the Section and line number to which they apply
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Sections 4-9 must be completed and submitted separately for each Development covered by this Application
Section 4: Description of Existing Development(s)
Most information should automatically populate from IMS/PIC information, except for Section 4, Line item 10 (Total Acres of the
Development) which the PHA must complete. If line 10 is not completed or less than proposed for disposition under Section 5, PHA
will not be able to fill in Section 5, line 4. The development number should be the HUD development number. All development
numbers are at least 8 characters long (and may be up to 11 characters for AMP developments).
Section 5: Description of Proposed Removal
Unlike section 4, this information will not automatically populate. PHAs must complete the fields of this form where there is no field
in the IMS/PIC SAC application for the requested information (i.e. UFAS information).
Removal Action Type: PHAs must select removal action type as the first step to creating the electronic SAC application in IMS/PIC.
Property description (Unit, Building, Acreage): PHAs identify the property by development number(s) and buildings by their IMS/PIC
building PHAs provide the total acreage (refer to instructions for Section 4, line 10) and physical address of the property proposed for
removal. If the removal action includes land (i.e., not just buildings), PHAs should attach a description of the land (e.g. survey, copy
of the legal description), along with a copy of the DOT/DoRC that is recorded against the property, if available. If the proposed removal
action (including demolition) is for only a portion of the property at a contiguous site, PHAs must attach a site map.
Estimated Value of Property: Attach an independent appraiser’s appraisal summary or other valuation method.
Timetable: PHAs indicates the number of days after HUD approval of a SAC application that they estimate they will complete these
activities.
Section 6: Relocation
PHAs complete this section for all proposed removal action where relocation will be required. PHAs may be required to complete
additional relocation information in the applicable addendums (e.g. right of first refusal for homeownership applications; evidence of
compliance with all applicable federal, state, and local laws for eminent domain actions).
For question #3, the summary of the type of counseling and advisory services should include a description of how the services will
promote fair housing, including but not limited to how they will assist residents in obtaining housing in opportunity areas.
For question #6, the relocation summary should provide sufficient detail about the comparable housing that the PHA will offer to the
displaced residents (i.e. based on available resources and resident preferences) Indicate how the PHA will identify and offer comparable
housing to (a) displaced residents who have a family member who is a person with a disability; and (b) displaced residents who are not
eligible for Section 8 HCV assistance (e.g. because they are over-income).
Note that a PHA’s eligibility to receive TPVs is based on statutory Appropriations laws, and other HUD guidance, including but not
limited to PIH Notice 2017-10and PIH Notice 2018-04 (or any successor or replacement notices).
If the PHA is a public housing only-PHA and will partnering with a PHA that administers an HCV program for the TPVs, the partnering
PHA must have jurisdictional authority and administrative capacity to administer the TPVs. PHAs should contact their local HUD
Office of Public Housing for more information.
Section 7: Resident Consultation
Refer to the regulation, PIH Notice or other HUD guidance document for guidance on resident consultation for the specific removal
action proposed.
Section 8: N/A
Section 9: PHA Certification of Compliance
The Executive Director, Board Chairperson, or other authorized agent of the PHA, should complete, sign and date the Certification and
submit it (as a scanned PDF file) as part of its submission of the SAC application.

Provide attachments as needed. All attachments
must reference the Section and line number to which they apply
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De Minimis Demolition
PHAs do not need HUD approval to demolish units under Section 18 de minimis authority. PHAs do need to submit information to
HUD described at 970.7(a)(1), (2), (12), (13), and (15), which includes PHA plan, description of the property, board resolution, and
environmental requirements. Thus, for purposes of de minims demolitions, PHAs are submitting information and not a SAC application
through this form.

Provide attachments as needed. All attachments
must reference the Section and line number to which they apply
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