HUD-40058 Claim for Rental Assistance or Down Payment Assistance (

Claim for Rental Assistance or
Down Payment Assistance
(49 CFR 24.402 and 24.401(f))

See back of page for Public Reporting Burden and
Privacy Act Statements before completing this form
For Agency Name of Agency
Use Only

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

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

Project Name or Number

Case Number

Instructions: This claim form is for the use of families and individuals applying for rental or down payment assistance under the Uniform Relocation
Assistance and Real Property Acquisition Policies Act of 1970 (URA) and may also be used by a 180-day homeowner-occupant who chooses to rent
rather than buy a replacement home. The Agency will help you complete the 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.
Displaced persons must rent/purchase and occupy a decent, safe and sanitary replacement dwelling within one year from the date of
displacement for replacement housing payment eligibility (see 24.402(a)(2)). All claims for payments must be filed no later than 18 months
from the date of displacement (see 24.207(d)).

1a. Your Name(s) (You are the Claimant(s)) and Present Mailing Address

2a. Have all members of the household moved to the same dwelling?
Yes
No (If “No”, list the names of all members and the addresses
to which they moved in the Remarks Section.)

Dwelling

1b. Telephone Number(s)

2b. Do you (or will you) receive a Federal, State, or local housing program
Yes

subsidy at the dwelling you moved to?

No

When Did You
When Did You Move When Did You Move
Rent/Buy This Unit?
To This Unit?
Out of This Unit?

Address

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.
I certify that I am: (check one)
_____ a citizen or national of the United States
_____ an alien lawfully present in the United States.

(2) Family.
I certify that there are ______ persons in my household and that
______ are citizens or nationals of the United States and _____ are aliens lawfully
present in the United States.

Household Income

6. Determination of Person’s Financial Means (Not applicable to 180-day homeowner-occupants
who choose to rent. Enter NA in Item 6(6).)

Claimant
(a)

For Agency Use Only
(b)

(1) Total number of persons in the household (See item 5(1) or (2))
(2) Annual Gross Household Income. (49 CFR
24.2(a)(14)). Enter
name of each household member with
income (include the
income of persons not
lawfully present in the
U.S.)

$

$

(3) Total Gross Annual Income (Sum of entries in item 6(2))
(4) URA low income limit for number of persons in item 6(1). If item 6(3) is greater than
item 6(4) - Family is not low-income. See 49 CFR 24.402 (b)(2)(ii)

$

$

(5) Gross Monthly Income (Divide item 6(3) by 12)

$

$

(6) 30% of item 6(5) or "NA". (If gross annual income item 6(3) is greater than URA low income
limit in item 6(4), enter "NA".)

$

$

Previous editions are obsolete

Page 1 of 3

$

form HUD-40058 (07/2006)

7.

Determination of Rent and Average Monthly Utility Costs (See 49 CFR 24.402(b))

Instructions: To compute the payment, entries on line (8) must reflect all utility services. Therefore, identify on lines (2) through (5) each utility necessary to provide electricity,
gas, other heating/cooking fuels, water and sewer. In those cases where the utility service is not covered by the monthly rent, indicate the estimated out-of-pocket monthly cost.
In those cases where the utility service is covered by the monthly rent, enter “IMR” (In Monthly Rent). Determine the estimated average monthly cost of a utility service by dividing
the reasonable estimated yearly cost by 12. If a monthly housing program subsidy (e.g., Housing Choice Voucher/Section 8, other) has been provided, enter the applicable amount
on line (7).

Unit That You Moved From
Unit That You Moved To
(For Homeowner-Occupant, rent
(Do not complete if claim is for
will be determined by the agency.)
down payment assistance.)
(a)
(b)
(c)
(d)
Claimant
For Agency
Claimant
For Agency
Use Only
Use Only
$
$
$
$

Comparable
Replacement
Dwelling
(e)
To Be Provided
By Agency
$

(6) Gross Monthly Rent and Utility Costs
(add item 7(1) through (5))

$

$

$

$

$

(7) Monthly Housing Subsidy, if applicable
(e.g., Housing Choice Voucher/Section 8, other)

$

$

$

$

$

(8) Net Monthly Rent and Utility Costs
(subtract item 7(7) from item 7(6)) (Enter these
amounts on the appropriate lines in Item 8.)

$

$

$

$

$

Monthly Cost

(1) Rent (The monthly rental amount due under the terms
and conditions of occupancy. If utilities are not included
in rent, list in item 7(2) to (5))
(2)
(3)
(4)
(5)

8. Computation of Payment: If you are filing for down payment assistance, check this box

and skip item 8(1).

(1) Monthly Rent and Average Monthly Utility Costs for Unit That You Moved To
(From item 7(8), Column (c))

To Be Completed
By Claimant
For Agency Use Only
(a)
(b)
$

$

(8) Amount of Payment Claim (Amount on item 8(7) multiplied by 42) (For a Homeowner-Occupant who elects to
rent, this amount cannot exceed the difference between the aquisition cost of the displacement dwelling and
the cost of a comparable replacement dwelling. See form HUD-40057, item 5(5).)
$

$

(2) Monthly Rent and Average Monthly Utility Costs for Comparable Replacement Dwelling
(From item 7(8), Column (e)) (To be provided by the Agency)
(3) Lesser of item 8(1) or (2) (If claim is for down payment assistance, enter amount from
item 8(2))
(4) Monthly Rent and Average Monthly Utility Costs for Unit That You Moved From (From item 7(8), Column (a))
(For Homeowner-Occupants who choose to rent, to be determined by the agency.)
(5) 30% of Average Gross Monthly Household Income (From item 6(6), Column (a)). If item 6(6) is "NA", enter
"NA" here.
(6) Lesser of item 8(4) or 8(5)
(7) Monthly Need (Subtract item 8(6) from item 8(3))

(9) Amount Previously Received (if any)
(10) Amount Requested (Subtract item 8(9) from 8(8))

$

$

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-40058 (07/2006)

To be Completed
by the Agency

10. Effective date (mm/dd/yyyy)
of eligibility for relocation
assistance

11. Date (mm/dd/yyyy) replacement
dwelling inspected and found
decent, safe and sanitary

13. Payment To Be Made In:

Lump Sum
(only for down payment assistance)
Amount of Payment
Signature

Payment Action

12. Date(mm/dd/yyyy)
person occupied replacement
dwelling

Monthly Installments

Other Installments
(specify in the Remarks Section)
Name (Type or Print)
Date (mm/dd/yyyy)

14. Recommended $
15. Approved

$

Remarks

Remarks continued on a separate page?

Yes

No

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 payment to help you rent
or buy a new home 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.
Privacy Act Notice: This information is needed to determine whether you are eligible to receive a payment to help you rent or buy a new home. 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 (URA), and
implementing regulations at 49 CFR Part 24. The information may be made available to a Federal agency for review.
Previous editions are obsolete

Page 3 of 3

form HUD-40058 (07/2006)