HUD-40057 Claim for Replacement Housing Payment for 180-Day Homeoo

Claim for Replacement Housing
Payment for 180-Day HomeownerOccupant (49 CFR 24.401)
For Agency
Use Only

U.S. Department of Housing
and Urban Development
Office of Community Planning
and Development

Name of Agency

Project Name or Number

OMB Approval No. 2506-0016
(exp. 07/31/2008)

Case Number

Instructions. This form is for the use of families and individuals applying for a replacement housing payment under the Uniform Relocation Assistance
and Real Property Acquisition Policies Act of 1970 (URA) for a 180-day homeowner occupant who elects to buy a replacement home. A homeowner-occupant
who decides to rent rather than buy should also use form HUD-40058. The Agency will help you complete this form. HUD also provides information
on these requirements and other guidance materials on its website at: www.hud.gov/relocation. If the full amount of your claim is not approved, the Agency
will provide you with a written explanation of the reason. If you are not satisfied with the Agency's determination, you may appeal that determination.
The Agency will explain how to make an appeal.
All claims for payment by a homeowner-occupant must be filed within 18 months after the latest of: a) the date of displacement or b) the
date of final payment for the acquisition of the real property. Displaced 180-day homeowner occupants muct purchase and occupy a decent,
safe and sanitary replacement dwelling within 1 year after the later of: a) the date of final payment for the displaced dwelling (for
condemnation, use the date just compensation deposited in court) or b) the date a comparable replacement dwelling is made available by
the agency (see 24.204).
1. Your Name(s) (You are the Claimant(s)) and present Mailing Address

2. Have all members of the household moved to the same dwelling?
Dwelling

1a. Your Telephone Number(s)

Yes

Address

No

(If "no", attach a list of the names of all members
and the addresses to which they moved.)
When did you
When did you move When did you move
buy this unit?
to this unit?
out of this unit?

3. Unit That You
Moved From
4. Unit That You
Moved To
5. Certification of Legal Residency in the United States (Please read instructions below before completing this section.)
Instructions: To qualify for relocation advisory services or relocation payments authorized by the Uniform Relocation Assistance and Real Property
Acquisition Policies Act, a “displaced person” must be a United States citizen or national, or an alien lawfully present in the United States. The certification
below must be completed in order to receive any relocation benefits. (This certification may not have any standing with regard to applicable State
laws providing relocation benefits.) Your signature on this claim form constitutes certification. See 49 CFR 24.208(g) & (h) for hardship exceptions.
Please address only the category (Individual or family) that describes your occupancy status. For item (2), please fill in the correct number of persons.
RESIDENTIAL HOUSEHOLDS
(1) Individual.
(2) Family.
I certify that I am: (check one)
I certify that there are ______ persons in my household and that
_____ a citizen or national of the United States
______ are citizens or nationals of the United States and _____ are aliens lawfully
_____ an alien lawfully present in the United States.
present in the United States.
6. Computation of Replacement Housing Payment (A homeowner-occupant
who elects to rent should complete only items 1, 3, 4 & 5)
To Be Completed By Claimant
For Agency Use Only
(1) Purchase Price of Comparable Replacement Dwelling
(To be provided by the Agency)
(2) Purchase Price of the Dwelling You Moved To (Not applicable for owneroccupant who elects to rent)
(3) Lesser of line 6(1) or 6(2)
(4) Price Paid by Agency for Dwelling That You Moved From
(5) Price Differential Amount (Subtract line 6(4) from line 6(3).
If amount on line 6(4) exceeds amount on line 6(3), enter 0) This is the
maximum amount for a homeowner occupant who elects to rent.
(6) Incidental Expenses (From line 7(10))
(7) Mortgage Buydown Payment and Other Debt Service Costs
(To be determined by Agency. See instructions in Item 8)
(8) Total Amount of Replacement Housing Payment Claim
(Add lines 6(5), 6(6), and 6(7))
(9) Amount Previously Received, if any
(10) Amount Requested (Subtract line 6(9) from line 6(8))
Previous editions are obsolete

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form HUD-40057 (2/2005)

7. Incidental Expenses in Connection With Purchase of Replacement Dwelling (24.401 (e))
(a)
Claimant

Instructions: Enter expenses incidental to the purchase of your new home. Do not include
prepaid costs such as real estate taxes. Attach a copy of the closing statement and other receipts.
* Not to exceed the costs for a comparable replacement dwelling.

(1) Legal, closing and related costs, including title search, preparing conveyance
instruments, notary fees, prearing surveys and plats, and recording fees
(2) Lender, FHA or VA Application and Appraisal Fees
(3) Loan Origination or Assumption Fees (Not Prepaid Interest).
(4) Professional Home Inspection, Certification of Structural Soundness, and Termite
Inspection
(5) Credit Report
(6) Owner's and mortgagee's evidence of title, e.g. title insurance *
(7) Escrow Agent's Fee
(8) State Revenue or Documentary Stamps, Sales or Transfer Taxes *
(9) Other Costs (specify)
(10) Total Incidental Expenses (Add lines 7(1) through 7(9).
Enter this amount on line 6(6)).
8. Mortgage Buydown Payment and Other Debt Service Costs (24.401(d))

(b)
For Agency
Use Only

$
$
$

$
$
$

$
$
$
$
$
$

$
$
$
$
$
$

$

$

Instructions: You are entitled to compensation to cover the additional costs you must pay to finance the purchase of a replacement dwelling. The "buydown" payment
covers those costs that result because the interest rate you must pay for a new mortgage is higher than the interest rate on your old mortgage. The maximum buydown
payment for which you can qualify is the amount needed to reduce your new mortgage balance to the amount which can be amortized with the same periodic payments for
principal and interest as those for your old mortgage. (The Agency is required to advise you of its estimate of the maximum buydown payment and the interest rate, term
and amount on which it was computed. You will need to borrow that amount over that term to qualify for the full payment.) If you have more that one mortgage on either
your old or new home, complete a separate Item 8(13) for each computation and include the total amount of all such computations on line 6(7). Note: A mortgage on your
old home that was in effect for less than 180 days before the Agency's initial written offer of just compensation for the property cannot be used as a basis for payment.
Also, if the combination of interest and points for the new mortgage exceeds the current prevailing fixed interest rate and points for conventional mortgages and there is
no justification for the excessive rate, then the current prevailing fixed interest rate and points shall be used in the computations.

(a)
Old Mortgage

Part A - Information from Mortgage Documents
(1) Outstanding principal balance
(2)

Annual interest rate of mortgage

(3)

Number of monthly payments remaining on mortgage

(b)
New Mortgage

$

(c)
Lesser of Col. (a) or (b)

$
%

%

Mos.

Mos.

Part B - Computation of Payment (Use mortgage amortization table with 6 decimal places.)
(4) Monthly payment required to amortize a loan of $1,000 in __________ months (8(3)(c))
at an annual interest rate of ________ % (8(2)(b))
(5) Monthly payment required to amortize a loan of $1,000 in __________ months (8(3)(c))
at an annual interest rate of ________ % (8(2)(a))

$
$

(6) Subtract line 8(5) from line 8(4)

$

(7) Divide line 8(6) by line 8(4) (carry to 6 decimal places)

$

(8) Enter old mortgage balance (amount on line 8(1)(a))

$

(9) Multiply line 8(7) by line 8(8)

$

(10) New loan needed (subtract 8(9) from 8(8))

Mos.

$

Note: If 8(10) is less than 8(1)(b), enter amount from line 8(9) onto line 8(13) and skip lines 8(11) and 8(12)
(11) Divide 8(1)(b) by 8(10) (carry to 6 decimal places)

$

(12) Multiply line 8(11) by line 8(9)

$

(13) Enter amount from 8(9) or 8(12), as appropriate
(This is the mortgage buydown payment)

$

(14) Other debt service costs
(Reimbursement of purchaser's points and loan origination fees is based
on the new loan needed (8(10)), or the actual new loan balance (8(1)(b)), whichever is less. Do not
include seller's points or any cost included as an incidental expense in 7(12).)

$

(15) Add lines 8(13) and 8(14). Enter this amount on 6(7).
$
9. Certification By Claimant(s): I certify that the information on this claim form and supporting documentation is true and complete and that I have not
been paid for these expenses by any other source.
Signature(s) of Claimant(s) & Date
X

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)
Previous editions are obsolete

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form HUD-40057 (2/2005)

To Be Completed by Agency
10.Effective Date of Eligibility
for Relocation Assistance
(mm/dd/yyyy)
Payment Action

Amount of Payment

13. Recommended

$

14. Approved

$

11.Date of Referral to Comparable
Replacement Dwelling
(mm/dd/yyyy)
Signature

12. Date Replacement Dwelling
Inspected and Found Decent,
Safe and Sanitary (mm/dd/yyyy)
Name (Type or Print)

Date (mm/dd/yyyy)

Remarks

Public reporting burden for this collection of information is estimated to average 1.0 hour per response. This includes the time for collecting, reviewing,
and reporting the data. The information is being collected under the authority of the Uniform Relocation Assistance and Real Property Acquisition Policies
Act of 1970, and implementing regulations at 49 CFR Part 24 and will be used for determining whether you are eligible to receive a replacement housing
payment for a 180-day homeowner and the amount of any payment. Response to this request for information is required in order to receive the benefits to
be derived. This agency may not collect this information, and you are not required to complete this form unless it displays a currently valid OMB control
number.
There is no assurance of confidentiality. This information is needed to determine whether you are eligible to receive a replacement housing payment
for a 180-day homeowner. You are not required by law to furnish this information, but if you do not provide it, you may not receive this payment or
it may take longer to pay you. This information is being collected under the authority of the Uniform Relocation Assistance and Real Property
Acquisition Policies Act of 1970, and implementing regulations at 49 CFR 24. The information may be made available to a Federal agency for review.
Previous editions are obsolete

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form HUD-40057 (2/2005)